LIBRARY OF CONGRESS, 



Chap..i:.„ Copyright No. 



Shell, 



Mf 



UNITED STATES OF AMERICA. 



NOTES ON THE 

MODEEN TEEATMENT OF 
FEACTUEES 



.J* BY 

JOHN B. ROBERTS, A. M., M. D. 

PROFESSOR OP SURGERY IN THE PHILADELPHIA POLYCLINIC, MUTTER LECTURER 

ON SURGICAL PATHOLOGY OP THE COLLEGE OP PHYSICIANS 

OP PHILADELPHIA 



WITH THIRTY-NINE ILLUSTRATIONS 




NEW YORK 
D. APPLETON AND COMPANY 

1899 




COPYSIGHT, 1S99, 
ET 

Dr. JOH>~ B. EOBEKTS. 
TWO COPIES REC 




; *»« 






PKEFACE. 

Ko injuries require more careful and judicious treatment 
than fractures; and in no branch of surgical therapeutics is 
the exercise of common sense followed by more satisfactory 
results than in the treatment of these lesions. A blind reli- 
ance upon therapeutic dogmas and the adoption of routine 
measures, without due consideration of the mechanical and 
pathological problems presented, have led to many disasters 
in this department of surgery. The essays brought together 
in this little volume represent the views announced at vari- 
ous times by the author, who has always believed that inde- 
pendent thinking leads to the abandonment of false theories, 
and aids in the search for truth. Some alterations have been 
made in the papers to bring them into accord with the author's 
present views. 

J. B. K. 

1627 Walnut Street, Philadelphia, 
April 1, 1899. 



CONTENTS. 



i. 

PAGE 

Exploratory Incision in the Treatment of Closed Fractures 

and Dislocations 1 

II. 

Subcutaneous Nailing in Fractures with Unusual Tendency 

to Displacement, 10 

III. 

The Pretention op Deformity in Fractures of the Extremi- 
ties, 13 

IV. 

Subcutaneous Tenotomy as an Aid in the Reduction of Frac- 
tures 20 

V. 
False Doctrine in the Treatment of Fractures, ... 23 

VI. 

Recent Advances in Treatment of Fractures of the Ex- 
tremities 31 

VII. 
Simplicity in the Treatment of Fractures, .... 34 

VIII. 
Refracture for the Relief of Deformity after Fracture, . 44 

IX. 

Fractures of the Cranium 65 



VI CONTEXTS. 



PAGE 

Subcutaneous Nailing, Exploratory Incision and the Ex- 
tended Elbow in Condyloid Fractures of the Humerus, 78 

XI. 

Treatment of Fractures of the Lower End of the Humerus 

and of the Base of the Eadius, 92 

XII. 

The Ignorance of Surgeons Regardestg Fracture of the 

Lower End of the Radius, 118 

XIII. 

Deductions from Forty-three Cases of Fracture of the 

Lower End of the Radius, Treated Withln Three Months, 121 

XIV. 

Heedlessness of Spltnts in Fracture of the Lower End of 

the Radius, . 124 

XV. 

The Necessity of Force in the Treatment of Colles' Fracture 

of the Radius 130 

XVI. 

Fracture of the Lower End of the Radius with Forward 

Displacement 133 

XVII. 

A Case of Fracture of the Lower End of the Radius 

with Anterior Displacement of the Carpal Fragment, . 140 

XVIII. 

Fracture of the Lower End of the Radius with Displace- 
ment of the Lower Fragment Forwards, .... 142 

XIX. 

The Treatment of Fractures of the Lower Part of the 

Tibia and Fibula, 154 



THE MODERN TREATMENT OF, 
FRACTURES. 



EXPLORATORY INCISION IN THE TREATMENT OF CLOSED 
FRACTURES AND DISLOCATIONS. 

Complete reduction, exact restitution of contour, and per- 
fect retention are the conditions of full success in the 
treatment of fractures. Deformity, impairment of articular 
movement, non-union and neuralgic pains are remote results 
of failure to obtain these desirable conditions. Since aseptic 
surgery has made possible the prevention of infective inflam- 
mations in most open fractures, it is quite probable that bet- 
ter reduction, coaptation and retention result in open than 
in closed fractures of the same grade and character of bony 
lesion. 

The recent application of skiagraphy to surgical diagnosis 
has proved that fractures seemingly well reduced and properly 
dressed with splints may be the seat of considerable deviation 
from the normal skeletal relations. At the Polyclinic Hos- 
pital recently, for example, a fracture of the middle of the 
radius, supposed to be well reduced and dressed, was shown, 
by the use of the Eoentgen ray, while the splints were in po- 
sition, to have its fragments overlapping to the extent of about 
half an inch. In another case a painful swelling at the seat 
of a former injury to the fibula was discovered to be due to 
unrecognized non-union at that point. The rigidity of the 
tibia prevented the lack of union of the smaller bone being 
detected, but skiagraphy showed it plainly. 



2 THE MODERN TREATMENT OF FRACTURES. 

Nearly fifteen years ago I advocated conversion of closed 
fractures of the cranium into open fractures by incision of the 
scalp, whenever uncertainty as to the character of the cranial 
lesion was prejudicial to intelligent treatment.* As part 
of my argument I said that no surgeon would hesitate to con- 
vert a closed recent fracture of the thigh or leg into an open 
one if it were impossible to replace fragments which were 
threatening life. I admitted that closed wounds are less seri- 
ous than open ones, but asserted that, with modern surgical 
methods, open wounds are preferable to closed wounds having 
inherent dangers that cannot be recognized without opening 
them. Further consideration and experience convinced me 
that this method should be extended to fractures in the limbs, 
even when life was not threatened, if obscurity of lesion or 
difficulty in reduction jeopardized function. Accordingly, a 
few years later, f I gave it as my opinion that recent fractures 
of the lower end of the humerus might with propriety be sub- 
jected to exploratory aseptic incision, if satisfactory coaptation 
was not obtainable under anaesthesia; and that such action, 
though it involved opening the elbow joint, was as legitimate 
in properly selected cases as the recognized exploratory inci- 
sion made in obscure abdominal conditions. 

My belief in the propriety and value of exposure of the 
fragments in a certain limited number of closed fractures has 
been strengthened as years have passed. The method, which 
I do not claim as novel, has, however, not been sufficiently 
impressed upon the profession to cause its adoption by sur- 
geons in general. Allis of Philadelphia has advocated it t- 
in rebellious fractures of the upper third of the shaft of the 
femur, in order to apply steel screws for retentive purposes. 
In England, Lane has employed it § in oblique fractures of 

* " Transactions American Surgical Association," vol. iii. (1885), pp. 6 
and 105. 

t " Transactions American Surgical Association," vol. x. (1892), p. 58. 

\ Medical News, November 21, 1891, p. 590. 

§ " Transactions Clinical Society of London " (1894), p. 167. 



EXPLOEATOEY INCISION W CLOSED FEACTUEES. 6 

the tibia and fibula near the ankle, for the same reason. Mc- 
Burney * and others have resorted to it in fracture of the 
upper end of the humerus complicated with dislocation. 
Dennis t and Eicard t also approve of it in cases where there 
is difficulty in obtaining correct apposition of fractures. 
Other writers may have mentioned the subject, and cases 
may have been occasionally reported ; but, except in fractures 
of the cranium and patella, I think that most surgeons are 
more apt to be satisfied with imperfect results than to advise 
immediate exposure of the fragments before the patient comes 
out of the anassthesia induced for the purpose of examining 
and reducing the fracture. 

This attitude of the profession in general has been evident 
in societies at which I have incidentally mentioned my 
views, § and is due to conservatism bred by the fear of open 
fractures felt by all in the pre-antiseptic period of surgery. 
The method has suggested itself to many practical surgeons, 
but it needs to be ever before our minds as a legitimate pro- 
cedure. 

My advocacy of cutting down upon closed fractures is 
limited to cases in which ignorance of the exact lesion, im- 
possibility of reduction, imperfect immobilization, or failure to 
deal efficiently with complicating lesions makes the incision 
the less of two evils. An aseptic incision is almost devoid 
of risk, even if it opens a joint; but that slight risk should not 
be added to the patient's burdens unless the probability of de- 
formity, of interference with joint movements or other func- 
tions, of pain, of paralysis, or of non-union justify it. Here, 
as in all departments of surgery, it is the surgeon's duty to 
exercise care and good judgment in selecting the method of 
treatment. To illustrate my meaning I cite fracture of the 

* Annals of Surgery, May, 1890. 

f "System of Surgery," vol. i. 

i " Traite de Chirurgie," Duplay and Reclus, ii., 376. 

§ Annals of Surgery, April, 1895, p. 457, and- Philadelphia Polyclinic, 
August 21, 1896. 



4 THE MODERN TREATMENT OF FRACTURES. 

patella, which I have never treated by incision and suture of 
the bone, because I have thus far always been able to satis- 
factorily bring the fragments together by hooks, subcutane- 
ous suture, or splint. In one or two instances I have almost 
decided to lay open the overlying tissues in order to obtain 
approximation by direct appliances, but I have finally not been 
obliged to do so. The open operation I believe to be legiti- 
mate, and probably needful in a very few selected cases, but 
I am opposed to it as a routine treatment. 

It is self-evident that the wound exposing a fracture must 
be aseptic, and that the operator who adopts incision must 
be familiar with the steps to be pursued at the inception of 
infective inflammation. A man who will hesitate to reopen 
the wound or drain the joint, at the moment septic premo- 
nitions show themselves, should associate a more energetic sur- 
geon with himself in such operative treatment of fractures. 
The risk of incising muscles and opening joints, if done in an 
aseptic manner by an operator familiar with truly aseptic 
and antiseptic surgery, is unquestionably very slight. Pri- 
mary union without disturbance of joint-function will be 
almost universal. 

If it once be admitted that the seat of a fracture can be ex- 
posed by incision, with little or no risk to life, there are many 
advantages that will at once suggest themselves: 

1. The exact lines of separation can be seen, and the sig- 
nificance of lines of comminution in relation to subsequent 
reconstruction can be fully appreciated. 

2. Coaptation need no longer be guessed at by the sensa- 
tions imparted to the examiner's fingers, separated as they are 
from the bone by varying thicknesses of muscle, fat and skin; 
nor need it be dependent upon the possibility of having con- 
veniences for taking a skiagraph. 

3. The fragments can be accurately fitted together, torn 
periosteum replaced, and muscular and facial bands, nerves 
and muscles disentangled from undesirable positions between 



EXPLORATORY INCISION IN CLOSED FRACTURES. 5 

the pieces of broken bone. This prevents deformity by per- 
mitting restoration of normal contour of the limb and lessens 
occurrence of non-union, neuralgia, atrophy, and anchylosis. 

4. When the osseus, muscular, and vascular relations have 
been restored, they can be perfectly maintained by the appli- 
cation of sutures, pegs, nails, screws or ferrules to the bone, 
and sutures or ligatures to the muscles, nerves, and vessels. 

5. The pain, due to extravasation of blood, rapid inflamma- 
tory exudation, or traumatic synovitis, is relieved by the re- 
moval of the clots and leaking out of exudation and synovial 
fluid. The interstitial pressure caused by extravasated blood 
and exudate has often heretofore caused surgeons to split the 
skin and deep fascia by long incisions, in very bad fractures, 
in order to avert threatened gangrene. A similar relief of 
tension in less urgent cases will undoubtedly lessen pain and 
suffering, though such operative treatment would ordinarily 
not be adopted. The incisions employed to uncover the frac- 
tures are therefore indirectly of value as relievers of pain. 

6. Pain is also lessened, in the few cases requiring direct 
retentive apparatus, because the sutures, nails or screws pre- 
vent motion between the fragments better than external 
splints. Muscular spasm or incautious movement has there- 
fore little opportunity to cause suffering. 

7. Fat embolism is probably less likely to occur in fractures 
liable to its occurrence, if early escape of the fatty debris is 
permitted by incision. 

8. Anchylosis from faulty position of fragments, irregular 
formation of callus due to stripped-up periosteum, and gluing 
down of tendons, will seldom occur after the fracture has been 
disclosed to the scrutiny of a competent surgeon. 

9. Eepair of the broken bone and functional restitution of 
the surrounding tissues occur more rapidly than when coapta- 
tion is imperfect, or when damaged muscular and other struc- 
tures are left to the unaided efforts of nature. Impairment 
of digital movements after fractures is probably often due to 



6 THE MODERN TREATMENT OF FRACTURES. 

coincident rupture or laceration of muscles, which might have 
heen repaired by suturing with catgut, if the surgeon had 
known of the existence of the complication. The aseptic 
wound affords him this opportunity: and afterward usually 
heals so rapidly that it is of no disadvantage to the patient's 
period of convalescence. This early restoration of wage- 
earning capacity is of great value to many patients. 

10. It not infrequently happens that a closed fracture seems 
to have been well set. and to have little deviation from the 
normal; and yet the patient has lost some of his availability 
as a machine. This is most likely to occur in the lower limb 
which, during locomotion, carries the entire weight of the man. 
A slight change in the axis of a bone or in the plane of an 
articulating surface may perhaps throw the weight upon the 
hip, knee, or ankle in an abnormal way, and induce a con- 
siderable and ever increasing disability. This contingency is 
usually avoidable after the accurate inspection of the injured 
bone permitted by uncovering the fracture by an incision. 

In vicious ttnion of fractures due to absence of treatment, 
or to injudicious treatment, I believe that it is sometimes much 
better to expose the seat of deformity and divide the deformed 
bone with an osteotome than to refracture subcutaneously by 
an osteoclast or the surgeon's hand. Many cases can indubi- 
tably be well treated by refracture withotit incision or by sub- 
cutaneous osteotomy: but if there be a reasonable doubt as to 
one of these methods enabling the surgeon to accomplish re- 
lief of the deformity, free exposure, such as I have just been 
advocating in recent fractures, is the proper treatment. 

A similar method of dealing with luxations which are not 
readily reduced by manipulation under anaesthesia is, in my 
opinion, preferable to a long continuance of unsuccessful ma- 
nipulations, the application of great power by apparatus, or 
the relinquishing of the attempt to restore the integrity of the 
joint. It is true that in all dislocations, except that of the 
spinal column and the backward luxation of the second 



EXPLORATORY INCISION IN CLOSED FRACTURES. 7 

phalanx of the thumb, reduction is usually readily accom- 
plished by skillful manipulation under anaesthesia, provided 
the attempt is made while the injury is recent. My conten- 
tion is that in recent dislocation, when this is not the case, 
and in old dislocations, arthrotomy should be promptly done. 
No surgeon would recommend allowing the displacement to 
remain without attempting reduction ; and I believe that com- 
pound pulleys or other methods of applying great force are 
usually more risky than prompt and thorough exposure by in- 
cision. Immediately before making the incision it Avould be 
well in most cases to make a final effort to reduce by ma- 
nipulation ; but this should not be earned to a sufficient extent 
to cause much bruising or muscular laceration. The presence 
of such traumatism would increase the liability to septic proc- 
esses, if imperfect asepsis allowed germs to gain access to the 
wound during the operation. 

Arthrotomy for irreducible dislocations is not a novel sug- 
gestion, for it has been repeatedly clone by many surgeons in 
old injuries. It has not, however, I think, been often adopted 
until after vigorous efforts have been made to subcutaneously 
replace the articular surfaces. Its use in luxations a few hours 
or a few days old, except perhaps in the fingers and toes, is 
probably almost unknown as an accepted surgical procedure. 
I believe it ought to be the approved treatment in a small 
number of cases. The advantages of the open method will at 
once be patent when the accidents that occasionally follow the 
employment of the older method are recalled. Fracture of 
the bone or laceration of artery, vein, or nerve is only likely 
to occur when the region is not exposed to the operator's eye. 
In case of impossibility to properly reduce the dislocation, 
moreover, the end of a luxated bone can be excised. This 
will probably nearly always give a better functional result 
than to allow the previous condition to persist. Excision is 
not infrequently required after attempts to reduce old luxa- 
tions without incision having proved unavailing. In an at- 



8 THE MODERN TREATMENT OF FRACTURES. 

tempt to reduce an old luxation of the humerus I have dis- 
placed the head of the bone in such a way that it rested on the 
brachial plexus and caused more tro\ible than the original de- 
formity. This would not have been the result, I think, if I 
had exposed the luxated bone by arthrotomy. If the open 
treatment is to be adopted it is evident that the patient will 
receive the greatest advantage if it be instituted before the 
head of the bone is altered in shape, the socket changed, and 
muscle and fascia contracted or adherent to surrounding tis- 
sues. The open method in addition gives opportunity to di- 
vide any ligaments, tendons, fascia?, and muscles which restrain 
reduction, to scrape out any material filling the socket, and 
to make provision for preventing recurrence of dislocation by 
retrenching the capsule or other plastic measures. 

Skiagraphy may have a field in this department of surgery, 
as in fractures, by indicating the character of the luxation be- 
fore the incision is made. It may, perhaps, be urged to this 
plea for a more general employment of exploratory incision 
in closed fractures and dislocations that there are great ob- 
jections to making a closed lesion of the osseous system an 
open one. 

I know of no objection except the risks inherent in anaes- 
thesia, the possibility of infection, the occurrence of serious 
bleeding, and the production of anchylosis. The objections 
are of no force when the injury is one requiring exploratory 
incision. Anaesthesia will have been used in such instances 
for diagnosis or attempted reduction. Its moderate prolonga- 
tion for the necessary time will add practically nothing to the 
risk. Bleeding is no contra-indication, except in that rare 
condition, hemorrhagic diathesis. Anchylosis is more liable to 
occur from displaced fragments of articular surfaces, irregular 
callus clue to stripped-up periosteum, and interference with 
articular contact, than from aseptic incision into the joint and 
readjustment of the joint structures. The possibility of in- 
fection is, then, the only factor that reqiiires consideration. 




EXPLORATORY INCISION IN CLOSED FRACTURES. 



Fifteen or twenty years ago, even subcutaneous tenotomy at 
the heel, recommended by the surgeons of the Pennsylvania 
Hospital in cases of marked displacement after fracture of the 
tibia, was undertaken with some hesitation. Now operative 
infection in muscular and osseous lesions is so preventable and 
so readily managed by prompt action that it is no longer a 
valid objection to incision in a closed fracture or dislocation, 
if functional disability is liable to occur unless this operation 
is performed. For some years it has been the practice of sur- 
geons to incise open fractures freely in order to thoroughly 
cleanse the deep recesses, obtain an antiseptic condition of the 
lesion, and get rid of the effused blood. An extension of 
operative surgery is, in my opinion, now warranted in closed 
fractures and dislocations in which ordinary methods of reduc- 
tion prove unavailing or unsatisfactory. 



II. 

SUBCUTANEOUS NAILING IN FRACTURES WITH UNUSUAL 
TENDENCY TO DISPLACEMENT. 

The safety with which fractures may be explored by 
aseptic incisions and the success of direct fixation, obtained 
by mechanical devices, have begun a revolution in the treat- 
ment of complicated injuries of bone. 

My attention has recently been directed, as a. result of read- 
ing, experience and some experimental work, to the value of 
fixation of closed fractures by subcutaneous nailing. All sur- 
geons use at times wires, screws, pegs, or nails to hold frag- 
ments together after adjustment of an open fracture or the 
operation of resection. 

It is now pretty well conceded that it is entirely proper to 
lay open the soft parts, and accurately examine with the fin- 
gers and eyes an obscure fracture which is difficult to reduce 
or to keep reduced; provided that the surgeon is familiar with 
the exact details of aseptic surgery and knows how to promptly 
meet the first evidences of septic contamination. I believe 
that it is similarly proper for a surgeon, with the same quali- 
fication and a sufficient knowledge of regional anatomy, to 
deliberately nail together the fragments of a broken bone with 
an aseptic wire nail, driven through the unbroken skin as a 
tack or nail is driven through a carpet into the boards of the 
floor. 

This operation will naturally be found most serviceable in 
oblique fractures of superficial bones like the tibia, and in 
fractures without comminution. It will be adopted with less 
safety in fractures involving joints, because of a greater risk 
of faulty asepsis; but even there a skillful and conscientious 
10 



SUBCUTANEOUS NAILING IN FRACTUEES. 11 

surgeon with a rigidly aseptic techniqxie will find no reason 
to reject the method. The careless surgeon who calls him- 
self an aseptic or antiseptic operator, but continually breaks 
the simplest rules of aseptic surgery, has no real right to 
operate in serious cases, and must be considered as debarred 
from operative undertakings of this kind. 

In comminuted fractures it may be impossible to employ 
satisfactorily subcutaneous nailing, because the exact reposi- 
tion of the pieces is impossible through the overlying swollen 
tissues; and because the avoidance of nerves and blood-vessels 
may be difficult, when driving the two or three nails which 
will be needed to fix the fragments firmly in place. In these 
cases an exploratory incision will disclose the nature and extent 
of the fracture line and permit the nails to be driven with 
accuracy. They should be so used, of course, only when their 
use is shown to be better than indirect fixation by splints ap- 
plied externally. 

Ordinary wire nails and a hammer are the only instru- 
ments needed in fixing fragments by the method here advo- 
cated. As wire nails are not tempered and often are not 
pointed, and as the exterior of the bone consists of compact 
tissue, it is rather better to have tempered steel nails or drills 
of various lengths made for the purpose; but this refinement 
is not at all necessary. Surgical needles, if long enough, will 
answer the purpose. I have had made slender steel nails of 
different lengths with drill-shaped points and long square 
heads. These fit into a common handle which is used while 
forcing the nail through the soft tissues and compact outer 
layer of bone. As soon as the hard bone has been perforated, 
the handle is detached and the nail driven into the fragments, 
held in correct position by the fingers; the long head is allowed 
to protrude. At the end of two, three, or four weeks, the nail 
is seized by the head with a pair of forceps and withdrawn. 

During the time the nail is in position the small wound of 
entrance is dressed with aseptic or antiseptic gauze; and a 



12 THE MODERN TREATMENT OF FRACTURES. 

slight additional support is given to the broken bone by any 
form of dressing which will prevent strain at the seat of frac- 
ture. A very light metal, wooden, paper, or gypsum splint 
may be employed for this purpose. 

This manner of dealing with fractures is by no means rec- 
ommended as a routine procedure, but is a legitimate and val- 
uable adjunct in dealing with broken bones having an un- 
usual tendency to displacement, whether the displacement be 
due to great obliquity of the line of fracture or to exceptional 
muscular contraction. 

Its advantages are simplicity of technic, effectiveness in 
meeting the mechanical requirements, and the ease with which 
the instruments required can be universally obtained. The 
only objection to the method in cases requiring such active 
treatment is the necessity for absolutely aseptic materials, and 
the observance, on the surgeon's part, of the same conscien- 
tious care, as to sterility of hands and skin, as is required in a 
successful intra-abdominal operation. 

Subcutaneous nailing will probably be found very valuable 
also in certain dislocations, such as dislocations of the clavicle 
from the sternum and the scapula from the clavicle. 



III. 

THE PREVENTION OF DEFORMITY IN FRACTURES OF THE 
EXTREMITIES. 

The deformity following broken bones is a frequent cause of 
litigation because the disability and unsigbtliness of the condi- 
tion are readily apparent to the patient and his friends. For 
the same reason the surgeon is more often subject to unfavor- 
able criticism than the physician, whose failure to do the best 
possible is often unknown to the public. 

So annoying is the sight of a deformed limb and so great are 
the responsibility and anxiety assumed in taking professional 
care of a bad fracture that some practitioners feel glad to have 
such cases fall into the hands of other physicians or to receive 
treatment at hospitals. 

Mistaken diagnosis is a common cause of deformity 
after fracture. It is necessary not only to know that a frac- 
ture exists, but also to be acquainted with the situation and 
general character of the lines of separation, if the surgeon is to 
obviate deformity. Many physicians fail in this important 
part of the treatment because they neglect to compare the in- 
jured with the uninjured limb; because they have forgotten 
the anatomical outlines of the region and do not take the trou- 
ble to look at the dry bones of the part while studying the 
injury; or, because they fail to examine the patient under gen- 
eral anaesthesia which prevents pain and relaxes the muscles. 

I have seen fractures overlooked because these precautions 
have been omitted. This is perhaps most often the case in 
fractures near joints where the normal mobility of the part 
and the irregular contour of the bones obscure the deformity 

13 



14 THE MODERN TREATMENT OF FRACTURES. 

and preternatural mobility due to the fracture. It has at 
times surprised me to find a peculiar curve in a bone of an in- 
jured limb existent also in the skeleton of the opposite 
side, proving that, which I at first supposed was an abnormal- 
ity due to fracture, to be natural configuration peculiar to the 
patient. Every doctor should have in his office the parts of a 
human skeleton. At times nothing so clearly straightens out 
an obscure diagnosis as a moment's inspection of the bare 
bones. An articulated skeleton is not necessary, and is rather 
expensive. The separated bones can be obtained through any 
medical student at very little cost from a dissecting room. 
Finer and more costly preparations, but no better for study, 
can be bought from the surgical instrument makers. 

General anaesthesia is not employed as often as it should be 
in obscure injuries. A few inhalations of ether will relax the 
tightened muscles and permit the surgeon to freely manipu- 
late the injured limb. The freedom from pain thus obtained 
is also desirable and prevents the unwise hurry which some- 
times is the cause of erroneous treatment at the hands of skill- 
ful and careful medical men. 

\Yhen it is impossible to make out the exact character of 
the fracture even under etherization and there exists bony de- 
formity which the surgeon is unable to correct, it may, in my 
opinion, be wise to make an aseptic incision down to the broken 
bone. This clears up the diagnosis, permits proper readjust- 
ment of the fragments, and only converts a closed fracture into 
an open one. "With our present aseptic and antiseptic methods 
of operating, the incision adds little risk to the case ; and may 
be of incalculable value in overcoming displacement and pre- 
venting premature deformity and disability. If the practi- 
tioner having charge of the case is not familiar with aseptic- 
surgery, he should seek the aid of a modern surgeon familiar 
with aseptic details. Suppuration must, of course, be avoided, 
and energetic relief measures must be promptly instituted if 
septic contamination occur. The wound, even if it look well 



PREVENTION OF DEFORMITY IN FEACTUEES. 15 

superficially, must be opened and drained if septic process 
begin in it. 

The Roentgen ray now gives us an almost perfect metbod 
of discovering tbe lines of fracture without incision. It is 
unfortunately not always available. 

When the diagnosis of fracture has been made, complete 
reduction of the fragments should be promptly accomplished. 
This is usually not a difficult task if the medical man is ac- 
quainted with the normal outline of the bone, compares the in- 
jured limb with the normal one and uses the skeleton of the 
arm or leg as a test of accuracy. The swelling which some- 
times obliterates the outlines may often be greatly diminished 
by elevating the limb for a few minutes, rubbing it with the 
hands from the fingers or toes toward the body, and encircling 
it for a few minutes with a rubber or flannel bandage firmly 
applied by spiral or spiral and reverse turns. These manipu- 
lations urge the serum upwards toward the heart and lessen 
the distention of the subcutaneous cellular tissue. The band- 
age must not be allowed to remain on the limb for more than 
a few minutes, lest it cause gangrene. It usually cannot be 
applied unless the patient be etherized, as it gives pain. 

In the green-stick fracture of childhood much force may be 
demanded to bring the bone into its normal shape. This 
should usually be done, even if the fracture is thereby made 
complete. The exception I make to this rule is in green-stick 
fractures of the clavicle. Complete fractures of the clavicle 
are often difficult to keep in perfect apposition. I therefore 
frequently desist from applying force sufficient to cause com- 
plete separation of the fragments in little children with green- 
stick fractures of this bone. I believe that the slight deform- 
ity which is left after partial restitution of the normal outline 
by moderate force, is likely to be less conspicuous than that 
which may result if I carefully separate the fragments and 
unavailingly try to keep the ends in perfect coaptation. If 
the child is very young, the deA'iation in shape will probably 



16 THE MODERN TREATMENT OF FRACTURES. 

diminish as the bone grows in length and thickens. If the 
child is nearly full grown, I am much more apt to attempt 
complete reduction, even if the bone does give way under the 
pressure of my fingers. 

In impacted fractures, considerable force is frequently 
needed to disentangle the interlocked ends. Unless this is ac- 
complished, reduction is incomplete, and deformity will per- 
sist. I think, at present, of but one instance in which it is 
unwise to attempt to separate the impacted fragments. Frac- 
tures of the neck of the femur in the aged have a character- 
istic indisposition to repair by bony union. Hence the inter- 
locked ends of the broken bone should not be pulled apart in 
the attempt to make a diagnosis or to obtain perfect restoration 
of the bony outline of the femoral neck. The deformity that 
will occur from the impaction is far less important than the dis- 
ability certain to remain after treatment, if the fragments are 
separated and non-union occurs. If the bony entanglement is 
undisturbed, osseous or cartilaginous union becomes more 
probable. 

This advice to avoid meddlesome activity applies only to 
fractures of the femoral neck in the aged. Under other cir- 
cumstances the impaction should be overcome and careful 
coaptation of the fragments sought. 

The fracture which probably most often gives rise to 
deformity is that of the lower end of the radius, with 
backward displacement of the lower fragment. In this 
injur}' the lower fragment is very often impacted or 
caught upon the dorsal edge of the upper fragment. It re- 
quires force suddenly applied with all the power of the sur- 
geon's hands to drive the lower fragment forward into its 
proper relation with the shaft of the bone. This is neglected, 
I fear, by a great majority of practitioners. Deformity much 
greater than necessary and a protracted convalescence, with 
pain and stiffness of the fingers are the consequences of the 
error. Immediate and thorough reduction will usually result 



PREVENTION OF DEFORMITY IN FRACTURES. 17 

in a rapid cure with little or no noticeable deformity. I have 
sometimes bent the lower end of the radius across my knee 
before I could disentangle the fragments and bring the lower 
one into place. This is not often necessary unless the fracture 
is some days old when first subjected to treatment. 

Deformity after unsuccessfully treated fractures may be 
prevented or relieved by refracturing the callus which unites 
the fragments. This is occasionally necessary in instances 
where no treatment has been given. The bone is bent across 
the edge of a padded table or over the surgeon's knee, and, 
after the bond of union has been ruptured, is treated as a 
recent accidental fracture. This may be done with success at 
the expiration of even six months since the seat of fracture re- 
mains weaker than the rest of the bone for a long time. There 
are various methods of applying the power of the surgeon 
who wishes to refracture such vicious union of a fracture; and 
the bone may be weakened or divided by drills, the osteotome, 
or the saw ; but these matters are foreign to the present discus- 
sion. 

To obviate the occurrence of distortion after reduction and 
coaptation of a fracture have been accomplished, some sort of 
retentive apparatus is required. In fractures of the thigh I 
usually employ permanent traction by means of a weight at- 
tached to the limb with adhesive plaster. This overcomes the 
tendency to overlapping. Any tendency to lateral displace- 
ment I antagonize by sand-bags laid along the sides of the 
thigh and leg or by molded splints. The molded splints 
may be made of bookbinders' pasteboard wet with water and 
applied to the limb before becoming dry or of gauze saturated 
with plaster of Paris and water. 

The best, and probably the cheapest, splints for fractures 
of the extremities are molded gypsum splints. Plaster of 
Paris, or gypsum, is obtainable in every region from store- 
keepers or druggists and costs but a few cents a pound. 
When added to water it forms a creamy mixture, which, as 



18 THE MODERN TREATMENT OF FRACTURES. 

everybody knows, soon " sets " or hardens into the familiar 
plaster used for covering the inner walls of our houses. A 
few strips or layers of cheese-cloth or mosquito-netting, 
saturated .with a moderately thick solution of plaster and laid 
upon the broken limb after the fracture has been set, soon 
stick together and harden, forming a splint which accurately 
fits every inequality of the limb's surface. The rigidity of 
the hardened gauze and plaster splints may be made as great 
as the surgeon pleases by placing more layers of gauze satu- 
rated with the plaster mixture upon the outside of the first 
layers, before the plaster in them has " set." If there is a 
tendency for any fragment to become displaced, the surgeon's 
fingers pressed for a few minutes on the outside of the splint 
so as to hold the piece of bone in position, makes a permanent 
prominence on the inside of the splint which acts as a substi- 
tute for his finger and does the same service as long as the 
splint is worn. 

These molded splints are held in place by a roller bandage 
:and are far better than any carved or manufactured splint 
ever made. They fit as a man's skin fits and need no padding 
to prevent bedsores. One splint may be applied on each side 
of the limb, or a single splint may be made so as to encircle 
the whole or nearly the whole of its circumference. Neigh- 
boring joints may be covered and therefore supported by the 
splint; or openings may be made in the splint where a wound 
needs frequent dressing or inspection. A little common salt 
added to the plaster mixture or the use of hot water for the 
mixture hastens its " setting "; borax or cream of tartar makes 
it harden more slowly. 

Such splints when applied as a first dressing should never be 
made to entirely encircle the limb; since the swelling incident 
to the fracture may make them too tight and cause much 
pain and even gangrene. If the plaster dressing is applied 
so as to encircle the limb, it should be cut open on one side its 
entire length before the surgeon leaves the patient. 



PREVENTION OF DEFORMITY IN FRACTURES. 19 

To prevent late deformity the surgeon must insist that no 
strain be put upon the newly formed callus until it is hard 
enough to bear the burden. This is particularly important 
in fractures of the femur and tibia, which in locomotion carry 
the entire weight of the patient's body. Oblique fractures 
of these bones are especially liable to bend at the seat of union, 
if the patient walks on them to early, without proper artificial 
support. It often requires very little additional support, but 
that amount may be essential. 

Quite recently I saw a gentleman with a deformed hand be- 
cause he had insisted upon rowing shortly after being treated 
for fracture of a metacarpal bone. The callus was too soft, 
and he now has a curved bone instead of a normally shaped 
one. 

The so-called ambulant treatment of fractures of the lower 
limb is very valuable in selected cases; but requires the gyp- 
sum splint to be adjusted in a special manner. It must be 
made so thick and firm as to carry the weight of the patient 
in walking and at the same time allow none of the weight to 
come upon the broken bone. 



IV. 

SUBCUTANEOUS TENOTOMY AS AN AID IN THE REDUC- 
TION OF FRACTURES. 

The treatment of fractures lias received much consideration 
in recent years and many suggestions of value have been made. 
Some practitioners, however, seem to regard fractures as in- 
juries belonging to a department of surgery in which no ad- 
vances have been made, and continue the routine measures of 
the last generation. It is this conservatism, or want of prog- 
ress, in surgical practice that leads me to call attention to 
tenotomy as an aid in the reduction of fractures with displace- 
ment. 

The suggestion was made a good many years ago by some- 
one; and has been used by many surgeons with great satisfac- 
tion. It is not employed as often as it should be, because its 
simplicity and effectiveness have received such scant recogni- 
tion. Its adoption by every physician who knows how to per- 
form an aseptic subcutaneous division of a tendon would, I 
am convinced, result in lessening the number of cases of de- 
formity after fractures — especially of the tibia and fibula. 
Surgical specialists are well aware of its usefulness in oblique 
fractures of the leg near the ankle; but I am not sure that 
even they adopt it as often as is desirable in fractures of the 
shafts of the tibia and fibula. One who has cut the tendon 
of Achilles in tibial fractures in which the ordinary fracture 
dressings seemed unavailing in preventing overriding and de- 
formity, will be pretty sure to adopt it in subsequent cases. 
The ease with which reduction is obtained and coaptation 
maintained is a source of much satisfaction, after such an 
operation. 



SUBCUTANEOUS TENOTOMY. 21 

It is essential that the skin and tendons be made aseptic and 
that the whole tendon be cut. If a few fibers are left undi- 
vided, the heel will still be drawn up by the calf muscles and 
the operation will fail of its object. If the operator can feel 
through the skin a distinct gap between the cut ends of the 
tendon, showing that the whole width and thickness of the 
tendon has been severed, the fragments will be easily adjusted 
and will lie in proper position with any simple form of reten- 
tive fracture dressing he may prefer. The pain due to spas- 
modic contraction of the calf muscles will be absent after such 
a tenotomy and the patient's comfort thereby greatly in- 
creased. The puncture made by the tenotome is to be covered 
by a compress of aseptic gauze or sealed with a little aseptic 
cotton or gauze held in place with collodion. 

This little operation, to which I have been resorting for 
years in selected cases, does not appear to impair the subse- 
quent power and usefulness of the foot. It obviates the neces- 
sity for complicated fracture appliances, to overcome spasm 
of the calf muscles which are causing pain and displacement 
of the ends of the broken bone. 

I have, so far as I recollect, only employed tenotomy in 
this manner for aiding the reduction of fractures of \h.e leg. 
It would probably be available in fractures of the upper part 
of the femoral shaft, when the iliopsoas muscle flexes and 
everts the upper fragment. The operation here would prob- 
ably require open incision and inspection of the parts, in order 
to devide the tendon without injuring important structures 
in its neighborhood. Tenotomy would perhaps take the place 
of cutting down upon and wiring the fragments in these 
troublesome fractures. 

The tilting up of the inner fragment in some fractures of 
the clavicle could probably be avoided by subcutaneous tenot- 
omy of the clavicular portion of the sterno-cleido-mastoid 
muscle. The upward displacement of the olecranon after 



22 THE MODERN TREATMENT OF FRACTURES. 

fracture might be managed in the same way, if it were diffi- 
cult to obtain and maintain coaptation. 

There is a possibility that intra-articular operations for 
bringing together the fragments in transverse fracture of the 
patella may be avoided by a free tenotomy and myotomy of 
the four-headed extensor muscle of the thigh. 



V. 

FALSE DOCTRINE IN THE TREATMENT OP FRACTURES. 

It is my desire to call attention to some points in connec- 
tion with the treatment of fractures which I believe to be 
errors, but which I think are accepted as axiomatic truths by 
many members of the profession. 

The idea is entertained by many that every fracture of the 
extremities should be treated by a special splint or apparatus. 
The simplicity with which fractures are treated by us in the 
Philadelphia hospitals has caused surprise to those practi- 
tioners who come to us for post-graduate instruction. Their 
previous teaching or reading has evidently created the mis- 
taken impression that complicated special devices are essential 
for each variety of broken bone. The fact that treating a 
fracture is a simple mechanical problem capable of solution by 
any device that will secure correct apposition and immobili- 
zation, while at the same time inflammatory conditions are 
prevented, is not recognized. 

The quite frequent use of a bandage, next to the skin, be- 
fore the splint is applied to the extremity is due to false teach- 
ing, and is fraught with danger because of the possibility of 
its causing unexpected constriction in the event of rapid in- 
flammatory swelling. This primary bandaging has been ad- 
vocated to prevent swelling and muscular spasm. That it 
does either to any beneficial extent is doubtful. We possess 
other and less dangerous methods that are more effectual for 
such purposes. 

It is quite commonly believed that ensheathing callus is one 
of the essentials of proper union after fracture, while the truth 
seems to be that ensheathing callus is seldom found except in 



24 THE MODERN TREATMENT OF FRACTURES. 

fractures of the ribs and other fractures where immobilization 
of the fragments is imperfectly accomplished. A fracture so 
held in proper coaptation that motion cannot occur heals with- 
out ensheathing callus in nearly all instances. Cicatrization 
goes on in bone wounds essentially as it does in wounds of soft 
parts. 

Early institution of passive motion during the treatment of 
fractures near joints or involving joints is still insisted upon 
by many practitioners. One of the greatest sources of anxiety 
to the young and inexperienced doctor is to know when to be- 
gin passive motion. He fears to begin too early lest he dis- 
turb the process of union ; he dreads to leave it too late lest he 
have an anchylosed limb as the result of his tardiness. The 
proper course, it seems to me, is something like this: If the 
joint is involved in the line of fracture passive motion at an 
earty stage will not prevent anchylosis, but may increase it by 
causing a greater degree of arthritis; if the joint is not in- 
vaded by the fracture line early passive motion is not needed, 
because anchylosis will not occur unless violent inflammation 
of the soft parts arises, which inflammation passive motion is 
more likely to increase than to decrease. In accordance with 
this view no vigorous passive motion should be made earlier 
than two or three weeks in any case. The adoption of such 
motion earlier than this has often in energetic but injudicious 
hands given much unnecessary pain, and perhaps in many 
cases increased the arthritis and subsequent stiffness. The 
degree of restoration of function possible after articular frac- 
tures is only determinable after many weeks. Passive motion 
should certainly not be commenced while arthritis is acute, 
and not as a rule until union of the fracture is pretty well ac- 
complished. When it is attempted the occurrence of arthritic 
reaction is an indication that it must be still longer postponed. 

The permanent stiffness of articulations after fractures in- 
volving the joint surfaces is nearly always due to imperfect 
reduction of the fragments or to infective synovitis. Passive 



FALSE DOCTRINE IN TREATMENT OF FEACTUEES. 25 

motion will not lessen the rigidity resulting from these causes. 
Massage and passive motion are, however, useful in nearly all 
fractures, by hastening absorption of effused blood and exu- 
date, stimulating the nutrition, and keeping the muscles sup- 
ple. They may be instituted immediately after the coaptation 
of the fracture, and be kept up during the entire period of 
treatment. Pain is an evidence that the passive motion or 
massage is doing harm, because arthritis exists or the move- 
ments are too vigorously employed. 

Splints and dressings are often continued too long, and 
thereby the disability of the patient for attending to his busi- 
ness is prolonged. In uncomplicated fracture of the tibia and 
fibula the patient should be able to go on crutches to his store 
or office in two or three weeks; provided that a silicate of 
sodium or a gypsum dressing has been applied. After frac- 
ture of the fibula of ordinary severity one week's confinement 
to the house is sufficient, provided that some supportive dress- 
ing be thereafter worn and crutches used. The usual un- 
comminuted fracture of the lower end of the radius needs no 
splint after ten days or two weeks. Although, of course, 
function is not perfectly restored, the hands and fingers can 
be used for many purposes involving little muscular effort. 
While not wishing to advocate rapid convalescence when cau- 
tion requires a few days' additional confinement, I hold that it 
is improper to keep a patient from pursuits that need his at- 
tention, merely because of the traditional idea that a fracture 
means six weeks' enforced idleness. Loss of money, mental 
anxiety, and continued disappointment of business connections 
are penalties too great to endure because of a tardy convales- 
cence insisted upon by routine practice. 

It is false doctrine that still insists upon the great risk in- 
curred when a closed fracture of the cranium is converted by 
the surgeon into an open one, in order to explore supposed 
dangerous characteristics which, if present, threaten life from 
probable secondary encephalic inflammation. 



Hb THE MODERN TREATMENT OF FRACTURES. 

The possibility of septic infection is increased, I admit, but 
so little that the danger of obscurity in diagnosis and conse- 
quent erroneous treatment is often much greater. 

Fractures of the nose have long been, and still are, often 
treated by useless dressings. The conventional application to 
broken nasal bones is a strip of adhesive plaster placed across 
the bridge of the nose Avith the idea that it will by its adhesion 
to the skin hold the broken fragment upward, and prevent de- 
pression of the nasal arch. That it is quite impossible for a 
flexible tissue like adhesive plaster to act in this manner will 
be recognized with the mere statement. If comminution 
tends to allow displacement, the plaster will not give sufficient 
rigidity to obviate the tendency. If it does no good, why dis- 
figure the patient by making him wear it? The proper 
method of retaining fragments in position when great ten- 
dency to displacement exists, is by transfixing pins: but as the 
object of this paper is not to deal with plans of treatment. I 
will not discuss the procedure at this time. Another custom 
quite prevalent is to put tubes in the nostrils after nasal frac- 
tures or operations, when we would all prefer mouth breathing 
to wearing nasal canulas. which are unsightly, uncomfortable, 
dirty, and which as a rule soon become clogged. Breathing 
through the mouth for a few days is easily borne when an 
acute nasal catarrh is contracted: therefore its performance 
after nasal injuries is not intolerable. If a plug is required in 
the nostril to maintain position of the fragments let it be intro- 
duced, and let it be a tube if you choose: but it will usually 
become clogged and offensive. A solid plug will in most in- 
stances be more cleanly. 

Deformities of the nasal bones and cartilages often become 
permanent after fracturing injuries because it is believed that 
there is little relief for the displacement, Properly con 
surgical treatment at the beginning or operative measures 
afterward will relieve much of the unhappiness resulting from 
unseemly lateral deviations and irregular contortions of the 



FALSE DOCTRINE IN TREATMENT OF FRACTURES. 27 

nose. The importance of this feature in the facial lines ren- 
ders defects in conformation so noticeable that in hypersensi- 
tive persons mental characteristics are often due to nasal 
deformity in childhood. It may be remembered that a com- 
mander of ancient times gave the order " aim at their noses " 
knowing that the enemy feared facial disfiguurement more 
than actual death. The false doctrines prevalent concerning 
nasal fractures should therefore meet an early overthrow. It 
is more important to treat a broken nose well than a broken 
leg. 

The use of the axillary pad in treating fractured clavicle 
is of little or no value. The important factor in the treat- 
ment is to so fix the inferior angle of the scapula that the- 
scapula cannot slide forward upon the lateral wall of the 
thorax, as it tends to do, because the clavicle, which is its only 
bony attachment to the trunk, is broken. 

Displacement of the fragments in broken clavicle is to be 
prevented by steadying the lower end of the scapula; and not 
by an axillary pad, which is ineffectual as a fulcrum against 
which to use the humerus as a lever to throw the acromial 
end of the clavicle outwards and backwards. The axillary 
pad is useless unless large and hard; if large and hard 
it cannot be worn without discomfort, that would usually be 
accompanied by danger of injurious pressure to soft parts. 

The employment of an internal angular splint for fractures 
in the vicinity of the surgical neck of the humerus is founded 
on false premises. The axillary muscles prevent the upper 
end of the splint extending high enough into the axilla to con- 
trol the upper fragment. Hence the splint does not keep the 
upper fragment at rest, and, by its projection beyond the elbow 
or hand, gives more leverage by which unexpected blows may 
cause motion of the lower fragment. It is better to use the 
thorax as a splint, and bandage the arm to the chest with per- 
haps a small amount of packing such as absorbent cotton or 
lint, in the axilla to steady the upper fragment. 



2b THE MODERN TREATMENT OF FRACTURES. 

The fallacy of treating fractures of the condyles of the 
humerus by anterior or posterior rigid angular splints, and 
thereby causing deformity and disability by impairing the 
external angular deviation of the axis of the upper extremity, 
was shown by A His some years ago.* Yet this is probably 
the method by which such fractures are treated by most of the 
members present to-day. The loss of the carrying angle of 
the arm after treatment of condyloid fracture by such splints, 
is, I have no doubt, a common experience, though many may 
not have recognized the cause. 

In fractures at the middle of the forearm, interosseous pads 
are seldom, if ever, required if the fragments are molded into 
proper position and the forearm is put in a position midway 
between pronation and supination. The interosseous space 
cannot easily be preserved by the use of an interosseous com- 
press, if the molding and the position mentioned will not do 
it. The bones are too much enveloped in muscles to be con- 
trolled by a superficial pad, even if it is long and narrow and 
hard. At least such will be found the case in most instances. 
A lamentable practice, founded on false doctrine, is the use of 
a straight — that is, flat — splint for the ordinary fracture of the 
lower end of the radius. The palmar surface of the lower end 
of the radius is concave, therefore the splint must be curved. 
Yet the practice of employing a Bond splint or some other 
form of flat splint is common. A convex splint or a splint 
with a hard pad, with a convex upper surface, is the only form 
of splint proper to use on the palmar aspect of the fracture, 
A straight splint Avill do well on the dorsal, but not on the 
palmar surface. Use, therefore, either a curved palmar or a 
straight dorsal splint if you desire cure with the least possible 
deformity. The stiffness of fingers and deformity, so fre- 
quently seen after these fractures, are due to imperfect reduc- 
tion of the fragments and improper splints. In some cases 
reduction without the application of any splint will give 
better results than reduction with the use of a flat splint. 
* "Transactions of Medical Societv, State of Pennsylvania," 1881. 



FALSE DOCTRINE IN TREATMENT OF FRACTURES. 2y 

The teaching that fractures of the shafts of metacarpal 
bones should be treated by palmar splints may not be univer- 
sal, but it is very common. In oblique fractures the deformity 
can often be overcome best by continuous extension adjusted 
to the finger by means of adhesive plaster, as it is done in 
fractures of the femur. Strips of adhesive plaster attached to 
the finger and an extending cord, preferably of rubber, 
fastened to a splint, placed under the wrist and palm and 
extending beyond the finger tips, is a serviceable dressing for 
correcting overriding in metacarpal fractures. 

The habit of measuring the length of the lower extremities 
in suspected fracture of the femur is founded on a mistaken 
impression that the legs are of the same length. The fre- 
quent asymmetry in length of normal limbs has been so often 
demonstrated that it is surprising to see surgeons constantly 
employ this method of diagnosis. Even if the legs were 
known to be of equal length, the measurement would probably 
be inaccurate, because of the difficulty of avoiding tilting of 
the pelvis and of applying the tape to exactly similar points 
on each side. When it is known that normal legs differ in 
length, the folly of placing any diagnostic dependence on the 
figures obtained is apparent. 

The disability liable to follow fractures of the femoral neck 
in patients beyond middle life is not as great as it is often 
stated to be. Whether this is due to a mistaken diagnosis 
between intracapsular and extracapsular fracture, I know not ; 
but I am convinced that the impression prevails to a great 
extent among the profession, that fracture of the neck of the 
femur in an old person means almost helpless lameness. Such 
is not the case. Very good use of the limb quite frequently 
happens. 

In oblique fractures of the legs with overlapping, reduction 
can at times be facilitated by tenotomy of the tendo Achillis. 
This means of overcoming displacing muscular action is per- 
haps not as often resorted to as it should be. 



30 THE MODERN TREATMENT OF FRACTURES. 

Extension by traction applied to the head and legs should 
be better known, I think, as a possible method of reducing 
fractures of the vertebrae. In many cases it will do no good, 
but in others it may. 

The aversion to applying coapting hooks to the patella and 
olecranon, Avhen apposition is otherwise impossible, is, in my 
opinion, the result of false teaching and observation. 

There are many points of this character upon which I might 
dwell, but I have said enough to indicate my disbelief in many 
of the popular traditions of surgical practice. I shall now 
wait to hear in the discussion that will follow, what justifica- 
tion for my beliefs or disbeliefs I can get from the practical 
men here present. 



VI. 

RECENT ADVANCES IN THE TREATMENT OF FRACTURES 
OF THE EXTREMITIES. 

Stjegeoks have recently made notable advance in the inves- 
tigation of fractures by the employment of the Eoentgen 
rays, which by means of the fluoroscope or photographic plates 
show the exact condition in obscure cases of fracture. In 
other instances, fractures which were supposed to have been 
properly reduced have been shown by the use of the Eoentgen 
rays to be still the seat of deformity. 

Another improvement is the freedom with which obscure 
fractures may be investigated by aseptic incision of the soft 
parts, which discloses the exact nature of the bony lesion. 

The treatment of fractures has been much improved in re- 
cent years by the more extensive adoption of plastic splints 
made of gauze and plaster of Paris. These should substitute 
to a great extent the manufactured splints of metal and wood, 
which instrument makers sell at a high price for use upon 
fractured limbs which they seldom fit. It is possible to prop- 
erly pad a wooden splint or successfully adjust a metal or felt 
one to the injured limb. It is, however, far better to make 
a splint out of plastic material like gauze filled with gypsum, 
which will absolutely correspond with all the inequalities of 
the surface of the patient's limb. 

Ambulant splints which permit patients with fractiu-es of 
the leg to get out of bed and walk upon the injured member 
at a comparatively early period are also the result of the ad- 
vance in fracture treatment that has come by study of the im- 
perfections of older methods. The employment of massage 
during the entire period of treatment of a fracture will be 
found to lessen the rigidity of muscles, stiffness of joints, and 



32 THE MODERN TREATMENT OF FRACTURES. 

inflammatory infiltration aronnd the seat of fracture which 
so often retard the patient's full recovery of function. Mas- 
sage should be used with discretion, but may be employed with 
much satisfaction to the patient every time the splint is re- 
moved for the inspection of the seat of fracture. The desir- 
ability of this method of establishing a healthy condition of 
the soft parts makes it desirable to remove the splints much 
more often than used to be thought necessary. 

Tenotomy of the tendon of Achilles to prevent muscular 
displacement in fractures of the leg near the ankle is another 
accessory of treatment often neglected. This little operation 
will probably be found of avail in some cases of fracture of 
the olecranon, and perhaps in other regions where muscular 
contraction leads to difficulty in maintaining reduction of 
•fragments. The surgeon should not forget that where ac- 
curate coaptation of the broken bone cannot be readily accom- 
plished, an aseptic incision will add practically nothing to the 
patient's risk. Such an incision not only gives a better under- 
standing of the condition of the parts which may be essential 
to proper treatment, but permits disentanglement of frag- 
ments of bone from lacerated muscles, thereby averting non- 
union of the fracture. It also permits the use of wire or cat- 
gut sutures in cases demanding such direct methods for main- 
taining apposition. 

It is probable that few surgeons, and perhaps almost 
no general practitioners, realize how easy it is to keep a frac- 
tured bone in position when the surgeon sees the exact line of 
break. Much of the deformity of many fractures would be 
overcome and the anxieties of the period of treatment lessened, 
if the medical attendant after finding the line of fracture 
simply drove a nail through the soft tissues into the broken 
bone in such a manner as to hold the pieces together. It is 
not improbable that the time is near at hand when many frac- 
tures will be treated by some such direct method. Ordinary 
wire nails or long tacks made aseptic can be driven through 



TREATMENT OF FRACTURES OF THE EXTREMITIES. 33 

aseptic tissues into the bone without disadvantage. This could 
be done in closed fractures as well as in open ones. An ordi- 
nary straight surgical needle does very well for this purpose. 
If necessary, an ordinary brad-awl may be used to drill the 
bone. 

Refracture or osteotomy of deformed union after fracture 
should be used much more frequently than it is. It is probable 
that much of the difficulty in fractures about joints comes 
from imperfectly apposed fragments. Investigation of such 
cases by free incision, and the use of nails or sutures in the 
bone to hold the fragments in proper position, would probably 
lead to more perfect restoration of function than is usual in 
fractures involving the joints. Many surgeons who fearlessly 
investigate fractures associated with wounds experience un- 
reasonable hesitation in making aseptic incisions down to the 
seat of fracture in obscure and troublesome cases. 

The recent advances here outlined in the treatment of frac- 
tures of the extremities have brought about the following re- 
sults: The restoration of the patient to a condition of health, 
permitting him to transact business in much less time than 
formerly; the establishment of this desirable end with little or 
no pain during the period of treatment; and the much less 
frequent occurrence of troublesome anchylosis after fractures 
involving joints. 



VII. 

SIMPLICITY IN THE TREATMENT OF FRACTURES. 

The essential factors in the treatment of broken bones are, 
undoubtedly, the early replacement of fragments, the preven- 
tion of recurrence of displacement, attention to the condition 
of the soft parts and due consideration of the patient's general 
health. After the reduction has been satisfactorily accom- 
plished, displacement may occur through the action of gravity, 
muscular contraction, or restlessness of the patient, and the 
surgeon must guard against such recurrence by applying some 
form of fracture dressing which retains the fragments in 
proper position. The best form of dressing will, as a rule, be 
that which corrects the tendency to displacement and at the 
same time steadies and immobilizes the limb. Special tend- 
ency to displacement varies with the line and position of the 
fracture, and should be recognized by the surgeon before he 
decides upon a form of dressing. 

Fracture dressings may be classed under three divisions: 
First, those which give moderate continuous traction or main- 
tain the extension which was applied when the fracture was 
first adjusted; second, those which by virtue of their rigidity 
or fixedness resist retraction ; and finally, those which by vir- 
tue of their inflexibility prevent angular or lateral displace- 
ment by furnishing lateral support to the fracture. 

These statements, which are almost axiomatic, will probably 
meet the approval of all the members of the society; but it is 
more than likely that in a general discussion of the subject 
there would be advocated a dozen different ways of treating 
the same fracture. It seems to me that surgeons often lose 
sight of the fact that simplicity in fracture dressing is as much 



SIMPLICITY IN THE TREATMENT OF FRACTURES. 35 

a surgical virtue as simplicity in the form of instruments used 
in surgical operations. 

Simplicity in the treatment of fractures is often neglected 
because of an obsequious reverence for the names of former 
surgical teachers, which have become attached to a splint or 
method of dressing. It is stated that legends and traditions, 
connected with historical places, never die; it is, unfortu- 
nately, true that surgical traditions have a similar lasting and 
often deleterious influence upon the progress of surgery. Il- 
lustrations of this are seen in the present use of Bond's splint 
for fracture of the lower end of the radius, an appliance 
founded upon an erroneous understanding of the nature of the 
injury, and one of the worst splints which can be used in its 
treatment. Physick's long splint for fracture of the femur 
is still used in this injury by many surgeons, who fail to 
realize that a more modern method of dressing is less trouble- 
some to the attendant and more comfortable and safe for the 
patient. Desault's dressing for fracture of the clavicle has 
now no value except as a puzzle with which to entangle un- 
happy students under examination; yet it is probably still em- 
ployed. 

Many books are filled with elaborate descriptions of fracture 
dressings, whose number seems to be limited only by the pa- 
tience of the author. Hamilton's " Treatise on Fractures " is 
so full of these complicated splints and devices that the young 
practitioner is hopelessly lost in selecting a method for treating 
a fracture under his immediate care. Individuals, as well as 
races, are born with mental characteristics which drive them 
to invent and advocate complicated methods in all the pur- 
suits of life. The English and German surgeons perhaps 
illustrate this tendency to an extreme degree. Some Ameri- 
can surgeons, partly from individual traits and partly from 
overdeveloped imitative faculties, are led in the same direc- 
tion. 

A truly Avonderful illustration of this perversion of the 



:- 



- 



:- : ■■:-. 1 iz. 1 :r.ri__T ■;-■; - j~ 1~ v : . Zr^izzL^" : 
"_.-.- I - - : : . . .. . .- : 

in proof of bit statement. ConH anything be more prepos- 
:<r.r:ci "l".".". "-- •..-■.-'.. '-1 ':~ ~ 11:1 : ; :■-. ---:_- —1:1 n. irili-.-r- 

ins is here treated. He is 
ill:-- :-:--- ~i 1. 1-1 —1:1 "7:1..-- :-z.\ -:1^ :~.::1^-' v 

\ . ::. r. ' 1 - . - .: 




- '_ .: -_f-'_"l ::' '^li^: — 1:1 :~ : sl~ztj. ~ 11 : 1 ::1- 
narOy needs seareely any splint, is a travesty of modem 
smgery. That even an Amwrikpain can accept such cffimpfi- 

eated dressing is shown by a risk to the waids of some of our 
huge metropolitan hospital I recently saw in a hospital in 
a neighboring city a patient with fracture of the thigh. The 



SIMPLICITY IN THE TREATMENT OF FRACTURES. 37 

dressing was a Physick's long splint, combined with the ex- 
tension apparatus of Buck and, I think, a plaster of Paris 
encasement: that is, this afflicted patient had about as much 
apparatus applied for his single fracture as would be required 
for the treatment of three patients with a similar injury. 
Any one of the appliances would be sufficient for an ordinary 
fracture of the femur. 

Physicians coming to Philadelphia are, I think, often sur- 
prised at the simplicity of the dressings used in some of our 
hospitals. It is certainly gratifying to know that we do work 
in a less complicated manner than is the case in some other 
cities. 

Another reason for a want of simplicity in fracture dress- 
ing is that students are often taught during their pupilage 
that each fracture has its special splint; hence they do not 
realize that the same form of dressing with very slight alter- 
ation Avill often answer for fractures in different parts of the 
body. 1 have never forgotten an expression used by Profes- 
sor Chiene of Edinburgh, who told me that he disliked ready- 
made splints as he did ready-made trousers; they never fitted. 

Few will dispute the desirability of simplicity, provided that 
simple measures meet the indications and fulfill the surgical 
objects. Simple dressings are always attainable, they are 
cheap, and are usually much more comfortable to the patient 
than more elaborate appliances. The latter are much more 
liable to become displaced and cause discomfort, and their in- 
tricacies are much less likely to be understood by the patient's 
friends or the hospital resident. The complication also tends 
to make the surgeon hesitate about removing the dressings, 
since much time, considerable assistance and no little skill are 
demanded in their replacement. For this reason complicated 
dressings are apt to be changed less frequently than simpler 
ones, and the progress of the fracture less often noted. I am 
quite convinced that simple appliances, which are readily re- 
moved and easily adjusted, tend to give better results, because 



6Q THE MODERN TREATMENT OF FRACTURES. 

of the more frequent examination and inspection given the 
injured limb. 

I would obtain simplicity by disregarding all the unneces- 
sary portions of dressings, and by selecting simple aitieles for 
retaining the fragments in apposition. The primary bandage, 
often applied to the limb before the splint is adjusted, is un- 
necessary and sometimes harmful: it is seldom used by prac- 
tical surgeons of to-day. Embrocations of lead water and 
laudanum and of similar drags, supposed to lessen the amount 
of inflammation at the seat of fracture, should be disregarded, 
as they have no potent influence in lessening the inflammatory 
exudate, and may perhaps by maceration of the skin lead to 
blebs on the surface of the limb. Proper coaptation and free- 
dom from muscular contraction are the factors most needed in 
the treatment of the inflammatory condition. \Vith omission 
of the primary bandage and the embrocations, which some 
surgeons cling to as a sort of fetich, there is nothing to be ap- 
plied to the fracture but the retentive apparatus. This should 
be of the simplest description. The surgeon who has sufficient 
individuality to refuse to pay for a carved or molded splint 
of metal offered by an instrument maker, will seldom have 
difficulty in dressing a fracture in a simple manner. 

The form of displacement and the character and seat of the 
fracture will give a hint to an observant surgeon as to the 
kind of apparatus to be used. Any form that tends to main- 
tain the proper contour of the bone ?.frer reduction is the one 
needed. If wooden splints are used, they should be very light 
and seldom thicker than the lid of an ordinary cigar box. 
Heavy splints with much padding are uncomfortable to the 
patient because of their weight and heat. In most fractures 
comparatively little strain is likely to be thrown upon the 
broken bone during treatment: hence a splint with a moder- 
ate degree of rigidity is all that is needed to prevent displace- 
ment. 

There is no question that the best splints in use are those 



SIMPLICITY IN THE TREATMENT OF FRACTURES. 



which are molded to the limb after reduction of the fracture. 
These fit any inequality of the surface Avithout padding, and 
therefore can be very light and worn with comfort. Molded 
splints are most readily made from butter-cloth or cheese-cloth 
dipped in plaster of Paris, paste, or glue. They are readily 
prepared, and can be molded to the form of the limb without 
giving the patient pain. In some cases almost no apparatus 
is needed because the parts may be put in the position which 
places the displacing muscles at rest and which insures proper 
coaptation of the fragments; for example, a fracture of the 



^--r^ 




»- ^ i 7 ,ii , 



Fig. 2. 
Splint made of layers of gauze stiffened with plaster of Paris. 

fibula, in which there is very little tendency to displacement, 
may be treated by simple bandaging, or even this may be dis- 
pensed with, because the parallel tibia makes an efficient 
splint. In some fractures of the phalanges an adjoining 
finger or toe acts as a good splint, or the finger of a glove made 
rigid Avill keep the parts in good position. A little additional 
firmness can be given to the glove finger by painting it with 
glue or mucilage. In the same way a stocking may be used 
as a splint by making it a little more rigid with starch, plaster 
of Paris, or other hardening material. 

The rapidity with which plaster of Paris mixed with water 
solidifies, makes it, by all odds, the best material for molded 
splints. Pelt or guttapercha may be softened, by dipping it 



10 THE MODERN TREATMENT OF FRACTURES. 

in liot -water, and then molded to the part; but these materials 
are not so easily obtained as gypsum or plaster of Paris, which 
is always to be found in any country store. Strips of gauze 
or other woven fabric may be converted into excellent splints 
by saturating them with plaster of Paris and water. Eight 
or ten of these strips applied to a limb soon become hard and 
hold the fragments in position. Lateral, anterior, or posterior 
splints of any shape may thus be made and are to be held in 
place by a roller bandage. The plaster of Paris must be kept 
dry, for if it has absorbed moisture it will not set. The set- 
ting may be retarded by adding a little dissolved glue or borax 
or cream of tartar, or by the use of cold water in making the 
mixture. Setting may be hastened by the use of hot water or 
by adding a little common salt to the water. It takes very 
little skill to cut V-shaped pieces out of the gauze and to over- 
lap the edges when the corners are to be turned : a moderately 
good surgeon can make a splint of this kind fit perfectly. In 
compound, or open, fractures, openings can be left or made in 
such splints. Strips of metal to further stiffen the splint, or 
metal rings for supporting a limb, may be incorporated in the 
layers of gauze and gypsum. 

Sometimes we can use another part of the body to maintain 
apposition of the fragments. Thus in fractures of the tipper 
part of the humerus the thorax is used as a splint when the 
arm is bound by a bandage to the chest. Fractures of the 
lower jaw are usually treated by using the upper jaw as a 
splint. 

In the treatment of open, or compound, fractures, less sim- 
plicity is possible in the first dressing; but the surgeon who is 
fully imbued with the doctrines of antiseptic surgery will 
usually be able to convert fractures of this kind into what are 
practically closed ones. Thoroughly laying open the injured 
regions, scraping out all particles of dirt, scrubbing the parts 
well with soap and water and a nail brush, and providing for 
removal or asepticity of all accumulations of blood will enable 



SIMPLICITY IN THE TREATMENT OF FRACTURES. 41 

him to put a dry antiseptic dressing and a splint upon the 
injured extremity, with the conviction that the wound will 
probably go on to recovery with very little variation from the 
clinical course of uncomplicated fractures in the same region. 
It perhaps will aid in the discussion of this subject if I give 
illustrations of simple methods of treating common fractures. 
It will be understood, of course, that my personal preferences 
are shown by these illustrations; but naturally there are many 




Leg dressed with anterior and posterior molded splints, with rings for sus- 
pension incorporated in the layers of gauze. Splints are indicated by 
dotted lines on the bandage. A shows form of wire in which rings are 
made. (From Stimson.) 

other equally simple methods of treating the same injuries 
which may be adopted by other surgeons. Necessarily these 
descriptions refer to such fractures of bones as are ordinarily 
seen, and not to cases of unusual severity. 

Fractures of the clavicle are usually satisfactorily treated by 
Sayre's adhesive plaster dressing, consisting of two long strips 
of plaster, which acts by drawing the upper part of the 
humerus backward, fixing the lower angle of the scapula, and 



42 THE MODERN TREATMENT OF FRACTURES. 

pushing up the elbow. Fractures of this bone unite with less 
deformity, as a rule, if the patient is kept upon his back for a 
week or ten days, so that the scapula is held in position by the 
weight of the body pressing against the hard smooth mattress. 
This supine position, with arm and forearm thrown across the 
patient's chest, usually allows the fragments to fall into proper 
position. Such recumbency for a few days gives a chance for 
the tissues surrounding the seat of injury to become more or 
less rigid with inflammatory exudate, and there is, therefore, 
little danger of recurrence of the deformity, when the patient 
is later allowed to walk about with Sayre's dressing applied to 
the injured region. 

Fractures of the upper end of the humerus are successfully 
treated by putting a single towel in the axilla and then band- 




Fig. 4. 

Anterior splint with axes of the two portions such as will preserve the car- 
rying function in fractures of humerus at elbow. 

aging the upper arm to the side of the chest, haying the fore- 
arm, which is otherwise free, carried in a sling. 

Fractures of the middle of the shaft of the humerus are well 
managed by an internal angular splint, preferably made of 
gauze and plaster of Paris. Fractures of the lower end of the 
humerus are best treated with the elbow in the extended posi- 
tion so as to retain the carrying function of the arm. I prefer 
holding it in position by a splint of wood having the obliq- 
uity of the normal axes of the arm and forearm or by means 
of a gypsum splint. 

Fractures of the forearm require an anterior and posterior 
straight splint, which should be neither too wide nor too nar- 
row. Fractures of the lower end of the radius usually require 



SIMPLICITY IJST THE TEEAT.MENT OE FEACTUEES. 43 

nothing but a wristlet or band of adhesive plaster carried 
around the lower end of the bone to restrict the movements of 
the wrist joint after reduction. Where there is unusual com- 
minution of the fragments, a straight wooden splint about six 
inches long and an inch wide placed on the back of the wrist 
is all that is required. Fracture of the olecranon demands 
scarcely more than a wooden splint about eight inches long 
and one inch wide in front of the elbow to prevent flexion. 




Fig. 5. 
Fracture of lower end of radius dressed with a wristlet of adhesive plaster. 



Fractures of the femur, whether of the neck or shaft or above 
the condyles, can generally be well treated by permanent trac- 
tion made by attached adhesive plaster and a weight fastened 
to a rope going over a pulley at the foot of the bed. By alter- 
ing the direction of the traction, the surgeon will find this 
method satisfactory in all ordinary cases. Sand-bags at the 
sides of the femur to prevent displacement or a short splint 
of binder's board around the thigh at the seat of fracture is 
the only additional apparatus likely to be needed. Some- 
times this can be omitted. For fractures of the tibia and 
fibula a fracture box, or plaster of Paris splint, meets all the 
ordinary indications. 



Yin. 

BEPRACTURE FOR THE RELIEF OF DEFORMITY 
AFTER FRACTURE. 

Kefbactube, or rupture of the callus, is only one of the 
methods of dealing with the deformity, but it combines the 
advantages of being available in a large majority of cases, and 
of being attended with a minimum risk. Gradual extension 
and pressure at the seat of deformity has been employed, but, 
as is easily seen, this will be of service only at the earliest 
stages of soHdifieation, and in truth should constitute the treat- 
ment of the fractxu'e from the very start, if there is tendency 
to angular displacement or overlapping. "When cases present 
themselves for the relief of distorted limbs the union is too firm 
to be affected by any such methods as this, which can only 
mold soft or semi-solid callus. 

In addition to pressure and extension, tenotomy may not 
unfrequently be of service in the early weeks of fracture by 
weakening the power of displacing muscles upon the broken 
fragments. It may also be needed as an assistant to refracture, 
when the surgeon chooses that method of managing the 
troublesome bones: but of itself it is, of course, valueless in 
meeting any deformity dependent on deposition of callus. By 
the term refracture I mean causing a separation of the frag- 
ments at the original site, which may be done by the applica- 
tion of external force alone, or by introducing, as a prepara- 
tory step, a perforator to weaken the union due to the large 
mass of callus usually deposited about fractures when the 
apposition is not good. The latter method makes, in many 
instances, a compound fracture, but still conies under the ap- 
pellation of a subcutaneous operation. I see no reason why 






REFRACTURE FOR THE RELIEF OF DEFORMITY. 45 

a narrow saw or a chain saw might not be introduced in the 
same way, and subcutaneous osteotomy done, as in cases of 
anchylosis ; but I do not know that this method has been used 
to any extent in separating badly consolidated fractures.* 

The more serious operations, such as excision of the ends of 
the displaced fragments and amputations of the limb, which 
may occasionally be adopted in instances of very great de- 
formity and inability to use the extremity, must be very sel- 
dom justifiable, and should only be employed when other 
means have failed. With these procedures the present paper 
has nothing to do, but shall be restricted to the consideration 
of refracture as described above. 

The first question in regard to this operation that must be 
discussed is: What are proper cases to be subjected to refrac- 
ture? This query can only be answered by investigating the 
matter in three directions, viz., the amount and character of 
deformity that demands operative measures, the locality of the 
original fracture, and the length of time after the primary in- 
jury that refracture of the malunion can be accomplished. 
By far the most frequent reason for having recourse to this 
operation is shortening of the lower limbs, preventing to a 
greater or less extent locomotion. A large protuberance of 
callus situated upon the femur or tibia would be a matter of 
little moment if the patient had perfect power of progression ; 
but it is because this mass of callus is present as a result of 
overlapping or angularity of the fragments, both of which 
circumstances cause shortening of the extremity, that the case 
calls for surgical attention. There is, of course, no algebraic 
formula to tell us how much shortening shall be considered 
equivalent to an operation; and it is well known that a con- 
siderable amount of shortening, at times nearly an inch, exists 
without inconvenience in many persons with uninjured legs.f 

* See Dr. Lente's suggestion under the modes of refracturing mentioned 
below. 

t W. C. Cox, American Journal Medical Sciences, April, 1875, and Jarvis 
Wight, Archives Clinical Surgery, February, 1877. 



46 THE MODERN TREATMENT OF FRACTURES. 

The most favorable cases for operation are those "where, on 
account of imperfect treatment, the fragments have united 
at their extremities, but not in the same line, and thus cause 
angular deformity and consequent shortening. The union in 
such instances is more readily ruptured, because the surfaces 
united are somewhat limited in extent, and the angularity of 
their position gives a good opportunity for disruption, by ap- 
plying pressure at the salient angle. In addition to being 
more amenable to separation, it is evident that the prevention 
of a recurrence of the deformity is more easily met by after- 
treatment than if the distortion were dependent upon over- 
riding of oblique smooth surfaces. Such cases, then, are emi- 
nently proper ones for treatment by refracture. Shortening, 
resulting from lateral apposition of the cylinders of bone, 
caused by want of attention to overcoming muscular displace- 
ment during the original treatment of the fracture, appertains 
to many cases: and such cases have by some been considered 
unsuitable for operative interference. They, however, be- 
lieved that in these cases the bond of union, though firm 
enough to support the -weight of the body in walking, -was. at 
least for a long time, fibro-osseous in its nature, and therefore 
could not be successfully raptured.* In attempting to dis- 
sever the fragments in instances of this nature, the force 
should, of course, be applied so as to bring transverse strain 
upon this uniting bone. If the bones are opposed with an- 
terior surface to posterior surface, the power should be ex- 
erted laterally: if side to side, the surgeon must use his force 
in an anteroposterior direction. Hamilton seems to think 
that there is little hope of gaining anything in length in 
cases of shortening caused by overriding, because the muscles 
have become permanently contracted by adjusting themselves 
to the new condition of things: f while George \Y. Xorris i 

* " Medico-Chirurgical Transactions.'' xlii., p. 26 1859 

\ " On Fractures and Dislocations," 4tli ed.. p. 475. 

X "Contributions to Practical Surgery," p. 120 (Philadelphia V 



EEFEACTUEE FOE THE BELIEF OF DEFOEMITY. 47 

doubts whether re-union would occur, owing to the rounded 
and smooth condition of the ends of the bones in such cases. 
This is, it seems to me, not a valid objection, because it is not 
probable that the bones could be placed end to end after re- 
fracture, and they would therefore lie alongside of each other 
with portions in apposition which had previously been united 
by the now ruptured callus. The shortening would be di- 
minished, but not so entirely overcome as to allow end-to-end 
apposition. Hence union would occur as in other cases. 

It must not be thought, howeA r er,that shortening preventing 
locomotion is the only indication pointing to refracture. In 
the upper extremity, especially, shortening is of little moment 
compared with freedom of motion in regard to flexion and 
rotation. Hence we see that the propriety of operation de- 
pends not only on the amount of deformity, but also upon its 
character. A distortion of the leg involving osseous deposi- 
tions between tibia and fibula would be a small inconvenience, 
while the same condition in the forearm avouM be a lamentable 
result of a badly managed fracture of the radius or ulna. 
Hence deformity which has allowed approximation of the 
bones of the forearm, and has given rise to restriction in rota- 
tion as a sequence, may very properly be looked upon as a fair 
indication for operation. Replacing the bones in perfect rela- 
tion with each other, and the subsequent absorption of 
unnecessary callus, may restore the functions of the parts to 
their normal standard, provided the time of operation be not 
too remote from the original injury. So also in fracture 
about the joints, where the deformed condition of the limb 
militates against flexion and extension, or the callus causes loss 
of muscular power, benefits may be derived from rupture of 
the callus and readjustment of the ends of the broken bones. 
Skey has operated also in cases where there has been persistent 
pain from pressure of nerve trunks in the callus, or entangle- 
ment of muscular or fibrous tissue in the same substance. 
Again, if the distortion be great, it may at times be justifiable 



48 THE MODERN TREATMENT OF FRACTURES. 

to operate for cosmetic reasons, just as benign tumors of un- 
sightly appearance are daily subjected to operative treatment. 
The general rule to govern the selection of cases may be 
formulated somewhat in this wise: When the deformity is 
attributable to causes incidental to the first fracture, but 
avoidable in the second, and is of sufficient degree to interfere 
with perfect motion or cause persistent pain or great 
unsightliness, refracture is to be employed as a means of relief. 
Unfortunately, cases presenting themselves for relief are 
usually those that have not been under observation during the 
treatment of the' fracture. It is therefore difficult to appre- 
ciate the causes of the deformity, whether it be due to great 
obliquity and smoothness of the fracture's surfaces, to great 
muscular irritability, to the unwillingness of the patient to 
submit to restraint or to the inefficiency of the original attend- 
ant. Consecpiently it is at times a question whether the dis- 
placing causes can be avoided in the after-treatment, and the 
surgeon has to operate without knowing exactly what agents 
are to give him most trouble. The mere matter of great mus- 
cular development certainly should not deter us as much as 
formerly, for with the improved method of extension and 
counter-extension it is possible to tire out any muscular masses 
that tend to produce displacement, and in certain cases tenot- 
omy may be called upon as an adjuvant to extension. 

The locabty of the fracture has some bearing on the pro- 
priety of the operation and the exact manner of performing it. 
A slight amount of shortening or even a decided crook in the 
humerus or clavicle is of little detriment to a man, while the 
distortion occurring in a woman or in the lower extremity of 
either sex, would perhaps be sufficient cause for undertaking 
an operation. Again, a degree of displacement of little mo- 
ment in the shaft of a bone may be a serious impediment to 
the free use of a ginglymoid articulation, or may interfere 
greatly with the tendons as they lie upon the expanded ex- 
tremitv of the bone. This matter of location is also of 



EEFRACTURE FOE THE RELIEF OF DEFORMITY. 49 

importance respecting the feasibility of refracture, for it is 
easily seen that it is exceedingly difficult to apply the ruptur- 
ing power when the def ormity is close to the hip or shoulder 
joint, for the upper fragment is not readily steadied during the 
manipulative processes. 

Another desideratum is the determination of the time after 
the original fracture that it is possible to tear asunder the 
united fragments. This necessarily must be variable, as so- 
lidification in fractures depends on sex, age, character and 
situation of lesions, and a host of other contingencies. 
Dupuytren, in a series of some fifteen cases, says * the period 
of resetting varied from twenty days to six months, and that, 
as a rule, the reunion was more rapid in the instances where 
readjustment was done early. It is well known that the 
greater the displacement the larger the amount of callus de- 
posited; hence it is more than probable that, in instances 
requiring readjustment, the callus is longer than usual in be- 
coming perfectly firm and bony. Skey believes that after 
four or five months the bone is often still fibro-osseous.f 
Nelaton believes t that it may be attempted as late as a year 
after the injury in adults, and even later than this in the case 
of children. Velpeau goes further, and says that angular de- 
formity may be broken at any period if there be much inter- 
ference with the function of the limb. Mr. Gay, at the Royal 
Free Hospital, London, refractured the femur for angular de- 
formity about twelve months after the original injury. § In 
truth, it may be said that absolute time has nothing to do 
with the matter, but that the surgeon must be guided by the 
practicability of refracturing the callus uniting the displaced 
ends, and this cannot be determined until trial has been made 
in each individual case. The only limit would seem to be 

* " Diseases and Injuries of Bones," Sydenham Translation, p. 70. 
f " Medico-Chirurgical Transactions," vol. xlii. 
X " Lectures on Clinical Surgery" (Atlee), p. 184. 
§ Lancet, 1850, vol. ii. p. 455. 



50 THE MODERN TREATMENT OF FRACTURES. 

tlie injury of the soft parts that might result from applying 
great power. This is fortunately giving us a wide range, 
since it is astonishing how much the surrounding tissues will 
tolerate without resenting the rude handling. Looking at the 
cases reported from the Pennsylvania Hospital, we find that 
severe inflammatory reaction occurred in none of them. If 
Ave recollect that high inflammation subsequent to ordinary 
fractures, that are not compound, is comparatively rare, and 
that, when found as a sequel, it is in great part due to the 
sharp spiculated fragments forced into the soft parts at the 
time of accident or during transportation, we can understand 
its conspicuous absence after refracture, where the ends are 
more or less smooth and rounded and the bones are placed at 
once in proper retaining apparatus. An interesting case is 
reported * by Dr. \Y~alter of Pittsburg, when he made, with- 
out success, protracted and vigorous efforts to refracture a 
femur at the end of about three months, and yet the patient 
got up the next day and complained only of soreness. At a 
later period he operated by cutting down upon the deformity. 
Skey operated on a fracture of both bones of the leg in a 
boy. where the union did not seem perfectly firm, at a period 
of thirteen months after the injury, and obtained a good re- 
sult, reducing the shortening from two inches to three-quarters 
of an inch, and enabling his patient to walk with scarcely a 
limp. The time, then, at which it becomes useless to attempt 
refracture cannot be fixed, but let the operation be tried in 
appropriate cases at any time, and let the surgeon be gov- 
erned in regard to amount of power only by the dangers to the 
soft parts, for, as far as the bone itself is concerned, it will 
break, if he can break it at all, at the seat of the former lesion. 
This question, however, will be discussed under the various 
objections that have been urged against the procedure as a 
treatment for deformity after fracture. 

It may be asked whether an operation would be justifiable 
* Medical and Surgical Reporter, Philadelphia, January 13, 1866, p. 28. 



EEFEACTUEE FOE THE BELIEF OF DEFOEMITY. 51 

in deformity resulting from fractures that have been care- 
fully watched and treated on the most approved principles 
from the beginning. The majority of cases that offer for 
treatment by refracture are, of course, maltreated or un- 
treated fractures which have not been seen before by the 
surgeon who is to operate. Should the same surgeon be will- 
ing to undertake refracture in a patient whom he had treated 
in the best manner from the time of original injury? I 
think this question should be decided affirmatively, if he 
thinks the experience gained in regard to the individual char- 
acteristics of this particular fracture renders it probable that 
he can overcome the displacing elements by some alteration 
in the manner of treatment, or by some additional co-opera- 
tion on the part of the patient. 

Having discussed the subject of selection of cases, I must 
turn now to consider the various procedures and appliances 
employed in effecting the desired rupture of the bond of 
union. The most simple method, when it is possible, is to 
bend the distorted limb into position with the hands, as is 
done when it is desired to straighten partial fractures occur- 
ring in childhood. This is only practicable when the union 
is of recent date or the bone small. 

I had written that any preparatory softening of the callus 
by poultices and fomentations was impracticable, when the 
following case reported by B. W. Switzer * met my eye. A 
Hindoo boy, aged four years, after sustaining a compound 
fracture of the right humerus, had received no treatment. 
Dr. S. saw him eight months subsequently, and found a large 
mass of callus without any motion or crepitus, and ordered 
inunctions twice daily, with 100 grains of iodide of potas- 
sium and 10 grains of iodine to the ounce of lard. Internally, 
the patient was given one grain of iodide of potassium twice 
daily. About three weeks subsequently crepitus was detected, 
and the mass of callus was found to be breaking up, which 
* Medical Times and Gazette, September 19, 1868, p. 352. 



Oii THE MODERN TREATMENT OF ERACTURES. 

process continued until all the callus was absorbed and the 
fragments were movable. The medication was then stopped, 
splints were used, and reunion occurred in good position. 
This seems to give weight to the opinion of Dupuytren, who 
believed that certain applications had a softening action upon 
callus. In regard to the application of the force, Skey says, 
" It must be persistent, because the rupture is a species of slow 
laceration or tearing, and occurs gradually." To this I must 
take exception. Although the callus in its early stages is 
fibrous and capable of being molded into shape by slow 
laceration, yet, in the majority of cases presented to 
the surgeon, the bond of union is firm, and, when ruptured, 
gives evidence of its solidity by a sharp snapping 
sound. When this is once heard, the problem is solved, and 
restitution can usually be effected. Hence it is that by a 
sudden force the uniting bond can be ruptured easier than 
by a gradual strain brought to bear upon it, just as a boy 
breaks by a sudden bend a stout stick that he could not tear 
apart by continuous pressure. When the fracture is too 
firmly consolidated to allow replacement by mere bending and 
rotation with the hands, it becomes necessary to use some 
method that gives a better opportunity of utilizing the 
strength of the operator. Thus, he can make a fulcrum by 
bringing the limb across the end of a table, or by placing a 
hard block or pad under the convexity of the angular dis- 
placement. Again, he can bind a straight splint along the 
limb from the seat of fracture to or beyond the distal ex- 
tremity, and thus control the joints and gain leverage; and. 
at the same time, by placing a similar support upon the limb 
above the point to be fractured, can render the occurrence of 
fracture at a new situation impossible. This, however, is 
probably never necessary. Another device of a mechanical 
kind is a screw-press or clamp by which great pressure can 
be exerted to break down the arch formed by the bones. 
Bosch of Augsburg, Pormann, and Oesterlen employed a 



REFRACTURE FOR THE RELIEF OF DEFORMITY. 58 

machine of this description, and, recently, Mr. Butcher 
adopted this method very successfully in a case of fractured 
femur of five months' duration where there were nearly five 
inches shortening and great angular deformity.* These 
methods are especially adapted to cases where the fragments 
have united at an angle. When the deformity depends upon 
lateral application of the two bony cylinders, rapture must be 
attempted by flexion across the bond of union, combined with 
rotation in the axis of the limb and strong extension and coun- 
ter-extension. As has been stated, these cases are less ap- 
propriate for treatment by refracture than the former variety. 
Indeed, in some cases of this kind, as well as in others where 
the shortening is great, it may be well to keep the patient 
etherized and continue the excessive extension for an hour or 
so after rupture, in order to gain as much length as possible 
before dressing the fracture. 

In order to obtain a firm hold upon the limb when making- 
extension by the compound pulleys, and yet to distribute the 




pressure so as not to bruise the tissues, Dr. Levis devised a 
serrated plate for the thigh to give attachment to the pulley 
rope. It consists of a strong iron hook, the upper part of 
which expands into a flat plate about seven inches long and 
two wide. This plate is slightly curved transversely to apply 
itself to the limb, and is roughened. On the upper surface 
* Dublin Journal of Medical Science, vol. lviii., 1874. 



54 THE MODERN TREATMENT OF FRACTURES. 

of this plate, at each side, there extends a longitudinal ridge 
serrated by deep notches cut into it. The appliance is ad- 
justed in the following manner: After a bandage has been ap- 
plied to the limb at the point selected, the plate and hook are 
laid upon it, then a strong cord is carried around the limb 
circularly and over the plate, catching in the sawlike teeth 
on the ridges above. This binds the hook and plate firmly 
to the limb just as sailors splice two spars together by a rope. 
Finally, the compound pulleys are applied and extension made 
as required without danger of the skin and muscles being lac- 
erated by the rope, since the pressure is distributed over a 
large surface. 

The osteoclast devised by Dr. C. F. Taylor of ISTew York 
for producing a transverse fracture at any selected point with 
ease, certainty, and safety from after-complications would, 
I should think, be applicable to refracturing the callus in 
deformed union, though the instrument was invented for frac- 
turing the femur in cases of anchylosis of the hip in which 
fracture was desired in preference to osteotomy. A descrip- 
tion of the appliance Avill be found in the ISTew York Medical 
Eecord, vol. xii., 1ST7, p. 241. The osteoclast of Eizzoli 
would also, no doubt, be applicable in certain instances. 

Brainard, in 1853, proposed introducing a drill and per- 
forating the callus in various directions subcutaneously, then 
allowing inflammatory softening to occur; and finally, after 
a lapse of some time, say ten days, restoring the crooked limb 
to its normal condition by force. His case was very success- 
ful, and may be condensed as follows: A boy, aged three years, 
had sustained a fracture of the tibia and fibula, two years 
and nine months preA'iously, which had left great angular de- 
formity and shortening of three inches. Perforation was 
done, and force applied ineffectually to refracture; the case 
Avas left ten days, and a further attempt at straightening was 
successful, though only a moderate degree of force was em- 
ployed. The cure was very satisfactory, and the patient was 



REFRACTURE FOE THE RELIEF OF DEFORMITY. 55 

able to walk.* A similar operation was performed by Dr. 
Stephen Smith, in 1860, upon a boy who had deformity, re- 
sulting from a partial fracture that had not been straight- 
ened.! Suppuration occurred in one of the two punctures 
made in the skin, but the distortion was improved. Nuss- 
baum has proposed to cut through three-quarters of the bone 
with a chisel, allowing the external wound to heal, and then to 
fracture the remaining fibers. This method does not leave 
sawdust or chips, as does the method which uses the perfora- 
tor or saw.J Dr. Frederick D. Lente of New York has sug- 
gested that the surgeon may accomplish the object by using a 
drill of very small size for perforating the center of the callus 
through a mere cutaneous puncture, and following this with 
an instrument, which he calls a subcutaneous saw, consisting 
of a narrow blade with a rounded point and saw teeth upon it 
for an inch from the end. This, being smaller than the drill, 
can be worked backwards and forwards inside the mass of cal- 
lus, and thus weaken it in any direction. § He had not em- 
ployed this operation at the time the article was written. 

"What are the objections urged against refracture as a means 
of relieving deformity from mal-union, and what are the 
dangers that may be encountered? The first objection to be 
suggested to anyone would be the possibility of the bone giv- 
ing way at a point more or less distant from the original frac- 
ture. This, however, is to be considered almost impossible, 
unless the bone be diseased and softened. It is a very dif- 
ferent condition of things from that where strong efforts, em- 
ployed for the rupturing of an anchylosed joint, are followed 
by fracture of the shaft of the bone. In the latter case, we 
have two large expanded articular surfaces firmly bound to- 
gether by adhesions, which have been deposited by a chronic 
inflammation, that has at the same time perhaps caused more 

* American Journal of Medical Sciences, 1859, vol xxxvii., p. 577. 
\ American Medical Times, New York, 1860, vol. i., p. 310. 
% Dublin Journal of Medical Science, October, 1875. 
§ New York Medical Record, vol. ii., 1867, p. 101. 



56 THE MODERN TREATMENT OF FRACTURES. 

or less disintegration of the neighboring bone. In the case 
under discussion, there are two overlapping fragments much 
smaller as a rule than the articular ends, and generally united 
at an angle by fibro-osseous matter. This must be much weaker 
than the normal bone above or below, even if a large amount 
of irregular callus has been thrown out around the seat of 
fracture. In fact, to one who has not made the experiment, 
it will be surprising to find how much force is required to 
break even so small a bone as the radius across the knee, when 
the bone has been divested of all the tissues and dried. Much 
more strength is requisite to fracture one of the bones of the 
extremities when it is surrounded by periosteum and buried 
in the muscular masses surrounding it. In order to test this 
matter I made some experiments on the cadaver where there 
had been no fracture. I drew the leg of the subject over the 
end of a table, and while an assistant steadied the thigh and 
knee as well as he could, endeavored to fracture the tibia by 
the manipulations that woiild be employed in refracturing a 
deformed union of the leg. I repeatedly threw all my weight, 
over 150 pounds, with sudden force upon the leg, but only 
succeeded in fracturing the fragile fibula, which being pos- 
terior and superficial, was brought in direct contact with the 
edge of the table without any muscular cushion. a[v assist- 
ant, who was stronger than I, failed also in his attempts to 
break the tibia. The only method which would avail to cause 
fracture of the tibia was to turn the subject on its face, in 
order to bring the subcutaneous surface of the tibia down- 
wards ; then by suddenly striking this portion of the bone pow- 
erful blows on the sharp edge of the iron table, I succeeded in 
producing an oblique fracture at the lower part of the middle 
third. These experiments show what a tremendous force 
would be required to fracture a sound bone by the manipula- 
tions used for refracturing deformed callus ; for in that opera- 
tion no one would ever think of selecting a sharp iron edge on 
which to strike the subcutaneous surface of the tibia. My 



REFRACTURE FOR THE RELIEF OF DEFORMITY. 57 

efforts fully convinced me that there was no possible chance 
of my succeeding in fracturing the femur, buried as it is in a 
large mass of muscles. The radius and ulna were only 
broken by the same kind of sudden blow over the table edge. 
It is a long time before the permanent callus becomes 
as firm and compact as the original bone, as is shown by the 
fact that, after once sustaining a fracture, the patient in fall- 
ing is exceedingly liable to refracture at the seat of original 
injury. A rather remarkable case bearing on this subject 
came under my notice a few weeks ago. The boy, who was 
eighteen years old, had a distorted forearm resulting from 
fracture about four and one-half inches below the point of the 
olecranon. His history was as follows: When eight years of 
age, he fell out of a tree and sustained a fracture of left fore- 
arm near the elbow. One year later he fell downstairs and 
broke it again in the same region, but says he thinks only one 
bone (?) was broken at that time. Three years subsequently, 
or when he was about twelve years of age, he fell into the hold 
of -a boat, and sustained a third fracture, but does not know 
whether both bones were broken or not. After this, he thinks 
the arm was as straight as the other, and straighter than it 
had been previous to this third accident; but there was some 
impairment of rotating power. Eight or nine weeks before 
these notes were taken, or nearly six years from the time of 
the third fracture, he fell from a coal-wagon, which, however, 
was not in motion, and sustained a fourth fracture, which from 
the present appearances must have involved both bones. 
Here then is a case where refracture occurred in the same po- 
sition, as near as may be, four successive times at intervals of 
one, three, and six years, due evidently to the natural weakness 
of the bond of union, for the fractures resulted from injuries 
that would probably have been productive of other fractures 
if there had been any constitutional predisposition to fracture 
in the patient's skeleton ; moreover, they occurred in a young 
person when solidification is supposed to occur rapidly. This 



58 THE MODERN TREATMENT OF FRACTURES. 

liability to fracture at the original lesion lias been repeatedly 
noticed, and is said to be equally true in animals.* 

The period required to give the bond of union the solidity 
of original bones — if, indeed, that ever occurs — must therefore 
be looked upon as indefinitely long. Suppose, however, it 
were possible to have the bone give way above or below the 
seat of deformity, would it not give the surgeon an oppor- 
tunity of making a compensatory cure that would be advan- 
tageous to the patient? 

The objection to refracture, advanced by some, that erysipe- 
las, abscess, necrosis, or pysemia may result, can be dismissed 
in a few words. Everyone knows the extreme infrequency 
of these occurrences in non-complicated simple fractures. 
The original injury has, in nearly all these cases, been attended 
with more disturbance of the tissues than is caused by the 
operation of refracture. Moreover the patient is in good condi- 
tion, the bones have rounded ends and do not lacerate, and the 
fracture is dressed without suffering the jarring and jolting of 
transportation. From the cases that I am cognizant of, I am 
inclined to believe that inflammation of a character sufficient 
to cause swelling and tension of the parts is exceedingly rare. 

I have mentioned above, when speaking of the time after 
injury that refracture may be attempted, the case of Dr. 
Walker, where his strong, though unsuccessful, efforts were 
followed by so little inflammation that the patient was up on 
the following day. Skey has reported a similar case. 

There seems also to be no real danger of rupturing ves- 
sels that have become shortened by reason of the decreased 
length of the limb. A much more important topic remains. 
Is there not danger of non-union after refracturing a firmly 
united bone ? Though we must admit the possibility of such 
an event, since Dr. Whitridge has reported f an instance sub- 

* Holmes' " System of Surgery," vol. ii., p. 96. 

\New England Medical Review and Journal, vol. i., 1827. Quoted by 
Norris in " Contributions to Practical Surgery." 



KEFRACTURE FOR THE RELIEF OF DEFORMITY. 59 

sequent to refrftcture of the radius and ulna, I believe it to be 
about as unlikely as non-union of the soft parts after incision 
through an old cicatrix, provided, of course, that the fracture 
receives proper treatment. Velpeaxi states that these new 
fractures consolidate, as a rule, more readily and easily than 
the primitive fractures. This may depend on the fact that 
there is required much less repair of muscular tissue and less 
absorption of blood, which processes are preparatory steps in 
the union of fractures of an ordinary variety. Oesterlen 
gives seventeen cases of rupture, and in no case did union fail 
to occur.* Moreover, ununited fracture, unless there be con- 
stitutional reasons, is rare in any event except as the result of 
imperfect treatment, which has allowed mobility of the frag- 
ments, or of the presence of portions of tendon or muscle be- 
tween the ends of the bone. These factors are eliminated in 
the case imder discussion where you have selected a favorable 
time as to the health of the patient, have dressed the limb with 
appropriate apparatus, and where there is little or no oppoi*- 
tunity for tissue to become entangled between the ends of the 
bone. The great infrequency of non-union in well-treated 
fractures is shown by the statistics of Norris. The number 
of fractures of all bones treated in the Pennsylvania Hospital 
from 1830-50 was 2190, among which there occurred, says 
Norris,t no instance of aitificial joint. The only cases of un- 
united fracture observed during that period were those sent to 
the hospital from distant parts. Of course some of these 2100 
patients died, and some were removed by friends (about 400 
altogether), and it is impossible to say what would have been 
the result if they had remained; one or two, perhaps, might 
have been examples of ununited fractures. Again, in Belle- 
vue Hospital, New York, from 1865 to 1873 inclusive, there 
were 128 fractures of the shaft and condyles of the femur, 
of which the result was known, and in this number there oc- 
curred only two examples of non-union. $ 

*Norris, loc. cit. \ Op. citut., p. 143. 

X Frederick E. Hyde, New York Medical Record, 1875, vol. x., p. 513. 



60 THE MODERN TREATMENT OF FRACTURES. 

Malgaigne tells us that Lonsdale saw only five or six in- 
stances of non-union among nearly 4000 cases of fracture 
treated at the Middlesex Hospital.* These statistics, though I 
always distrust statistics, give an idea of the comparative infre- 
quency of deficiency of union after fractures. The persistency 
with which union occurs is well shown in the boy reported 
above, who sustained four fractures of the forearm, and yet, 
when seen eight or nine weeks after the last fracture, had fimi 
union. He would have been subjected to refracture by Dr. 
Levis, for relief of the deformity and pain resulting from last 
fracture, had he not become dissatisfied and left the hospital. 
I have looked carefully over a large number of journals and 
systematic works on surgery without finding any case reported 
where a false joint followed refracture, except that of Whit- 
ridge already mentioned. 

jSTorris states f that Sir William Fergusson once amputated 
a limb for ununited fracture of the femur occurring after the 
bone had been rebroken on account of malposition. This is 
probably a mistake, for I have referred to the original report 
of the case as cited by Xorris, and find that the ampi;tation 
was done for an ununited fracture, but the cause of the non- 
union is not given as resulting from refracture.! It must be 
recollected in this connection, I admit, that we are unfortu- 
nately apt to neglect reporting bad results following important 
operations, hence other instances of non-union may have oc- 
curred. As having some bearing on this part of the subject 
I may refer to a case where both the femur and the hu- 
merus were ref ractured at the same iime, and union took place 
in six and a half weeks without difficulty. Again, it will 
be proper to refer to a man who had originally frac- 
tured both humeri as well as the leg, and yet, though the leg 
was rebroken after the lapse of six weeks, union occurred in 

* " On Fractures," translated by Packard, p. 120. 
f " Contributions to Practical Surgery," p. 131. 
t Lancet, vol. ii., 1850, p. 653. 



BEFEACTUEE FOE THE BELIEF OF DEFOEMITY. 61 

six and a half weeks without any trouble. A similar instance 
may be mentioned by me in which a boy had the radius and 
ulna of one arm broken in two places at the time of the frac- 
ture of the femur. Union occurred at all the fractures, and 
after refracture of the femur it united readily a second time in 
eight weeks. These facts are mentioned to show that there 
seems to be no narrow limit to the capability of the healthy 
system furnishing callus for the consolidation of multiple or 
repeated fractures. 

Death may undoubtedly follow this, as indeed it may the 
most trivial operations, and Haly Abbas, Morgagni, and Lau- 
gier have each recorded such a result. The repeated allusions 
to these same cases, however, in the text-books, show how in- 
frequent the occurrence is. 

The after-treatment of cases of refracture is sufficiently 
plain. In some instances it may be well to keep up great ex- 
tension with the pulleys for an hour or so after refracture has 
been accomplished, in order to fully stretch the parts, and ex- 
ert a certain paralyzing influence upon the muscles which tend 
to displace the fragments. The most successful treatment 
will probably be some form of extension combined with well- 
directed pressure of splints and pads over the situation of the 
angular displacement. The extension method is of course 
applicable in refracture for deformity of the upper as well as 
the lower extremity, though not so frequently required. The 
extending weight should be sufficient to do the work, and if 
adhesive plaster strips will not bear the strain, it may be re-en- 
forced by the application of some apparatus made of straps 
and buckles. If the fracture is low clown near the 
ankle, it may be necessary to use a footboard, strapped to 
the sole of the foot, in order to get attachment for the ex- 
tending weight. The necessity of employing splints of wood, 
pasteboard, or felt at the seat of fracture is obvious, since the 
extension merely obviates overriding, without keeping the 
fragments at rest or preventing angular or rotatory deviation. 



62 THE MODERN TREATMENT OF FRACTURES. 

In occasional instances tenotomy may be required to assist 
in preventing displacement, and this is not to be deprecated, 
for it does not add much to the severity of the operation, since 
the tendon cut is generally at a distance from the frac- 
ture, and hence the puncture does not make the fracture 
compound. 

The most important consideration is yet to be discussed; 
namely, the results of refracture as to the relief of deformity, 
and in regard to the usefulness of the limb afterwards. In 
this paper I have endeavored to collect all the cases that have 
occurred in the Pennsylvania Hospital from January, 1873, to 
December, 1877, excluding, of course, those which were treated 
by excision or drilling, because they were subject to different 
conditions, from the fact that more or less air had access to 
the seat of fracture. It was my intention to collect a much 
larger number of cases from the periodical literature of the 
last twenty-five years. After looking over many pages of 
journals and text-books I obtained some thirty additional 
cases occurring in America; I found, however, that no re- 
liable deductions could be drawn from these, because of the 
well-known fact that practitioners are loath to report un- 
successful operations, and because, on the other hand, many 
cases were only partially reported, and dozens, doubtless, were 
never recorded at all, owing to the supposed unimportance of 
one or two operations of this kind. 

My investigation of the records shows that during the time 
mentioned eight patients were treated in the hospital by re- 
fracture; the number of operations, however, was nine, 
because one patient had both an upper and a lower extremity 
operated on at the same time for deformity, resulting from 
mal-union. In all cases tabulated except one there 
was very marked amelioration of deformity, and, as far as 
relief from lameness, etc., is concerned, we may consider the 
patients cured. This is very noticeable in the refractures of 
the femur, because we have the amount of shortening before 



REFRACTURE FOR THE RELIEF OF DEFORMITY. 63 

and after treatment recorded. In the four cases it was re- 
duced to one-half inch, one-half inch, none at all, and one- 
quarter inch respectively; while before treatment there was 
three and one-half, one and one-quarter, one and one-half, 
two and three-quarters inches. Another feature is the non- 
occurrence of marked inflammation after the violent manipu- 
lations necessary to effect rupture. In the hospital notes I 
find no mention of any such occurrence in any case of the 
whole number, and reference to the fact would hardly have 
been omitted in the running notes of the patients if it had 
occurred to any extent. The time of treatment after refrac- 
ture will be found to be about the same as usually required 
for the uniting of ordinary fractures in similar situations. 
I have calculated the time by counting the number of weeks 
between the day of operation and the day on which the splints 
were discarded and the union found to be firm, though in 
cases of fractures of the lower extremity the patient was re- 
quired to sustain a portion of his weight on crutches or canes 
for some time longer as a precautionary measure. This, of 
course, would vary much with different surgeons and attend- 
ants, and has therefore been left out of the calculation. 

The lessons taught by an examination of these cases may be 
formulated as follows: 

Eefracture is the best method of correcting deformity after 
mal-treated fractures, because it gives relief without suppura- 
tion, which is more liable to follow osteotomy or excision ; and 
these operations are still available if it is difficult to refrac- 
ture the bone. 

It may be undertaken whenever there is a possibility of 
overcoming the causes that gave rise to the deformity after the 
original fracture. 

The time is only limited by the ability of the surgeon to 
rupture the bond of union. 

Eefracture is accomplished by bending, either alone or com- 
bined with powerful extension. 



64 THE MODERN TREATMENT OF FRACTURES. 

If the bone be healthy, there is no danger of fracturing in 
any situation but that of the original lesion. 

The occurrence of erysipelas, abscess, necrosis or | 
is too rare to be considered an objection to the operation. 

Xon-union almost never occurs. 

The results as to correction of deformity and as to useful- 
ness are uniformly satisfactory. 



IX. 

FRACTURES OF THE CRANIUM. 

The conversion of a closed (simple) fracture of the cranium 
into an open (compound) fracture by incision of the scalp is, 
with the improved methods of treating wounds, attended with 
very little increased risk to life. 

Uncertainty as to the character of a cranial lesion is more 
dangerous to health and life than the conversion of a closed 
into an open fracture of the skull. If I but learn the char- 
acter of the skull injury, I am acquainted with surgical ex- 
pedients that render restoration to health more probable than 
the complication due to the incision renders it improbable. 

Antiseptic methods have done away with much of the dan- 
ger of open wounds, as is shown by the frequent advocacy of 
resection for ununited and for malunited fractures, and of 
osteotomy and similar operations for conditions not urgently 
demanding surgical interference. No surgeon would hesitate 
to convert a closed recent fracture of the thigh or leg into an 
open one if it were otherwise impossible to replace fragments 
or avert danger to life. Hence I strongly advocate ex- 
ploratory incision of the scalp in obscure injuries of the skull. 

Some years ago a man, who, it was said, had fallen from 
a heavy wagon, and had been run over, was admitted into 
my ward of St. Mary's- Hospital, l^ehind the left ear was a 
large hsematoma, where it was asserted the wagon-wheel had 
struck him. My resident surgeon made a two-inch incision, 
and removed the clots; but, finding no fracture, closed the 
wound with sutures, and applied corrosive sublimate dressing. 
The knowledge that no fracture existed was very satisfactory, 
I can assure you. Three davs later, the incision had healed 



66 THE MODERN TREATMENT OF FRACTURES. 

up without suppuration except in a space of three-eighths of 
an inch, and the sutures were removed. Such rapid union 
without complication will not always occur, but it shows the 
possibility of little risk in the majority of cases. 

The removal of portions of the cranium by the trephine or 
other cutting instruments is, if properly done, attended with 
but little more risk to life than amputation of a finger through 
the metacarpal bone. 

Much of the mortality attributed to trephining belongs to 
the serious brain-lesions that have accompanied the fractures 
for which trephining has been done, and to the absence of 
proper surgical antisepsis. Many patients have been tre- 
phined and have undoubtedly died; but the opponents of tre- 
phining must show that cause of death lay in the operation 
itself. In deaths occurring from lesions for which trephining 
is the admitted treatment, they must likewise show that the 
operation was done early enough to remove the causative fac- 
tor of death before they can assert that the operation was un- 
availing. Gross, Michel, and many others have frequently 
quoted historical facts and cases which show the slight risk 
incurred by uncomplicated trephining. Briggs says: " My 
opinion, based on a large personal experience, is, that tre- 
phining the skull is one of the safest of the capital operations 
of surgery." * 

The opposite view, however, was held by Dr. H. F. Camp- 
bell, at a recent meeting of this Association, at which he said: 
" I have ever regarded trephining as one of the most serious 
of all capital operations." t 

Xancrede.i from a careful investigation, gives a mortality 
of 10.69 per cent, as being a probably fair estimate of the 
risk of the operation per se, and a death-rate of 15.29 per 
cent, as an expression of the probable risk in trephining a sim- 

* " Annals of Anatomy and Surgery," vol. vii., 1883, p. 65. 

+ " Transactions of the American Surgical Association," vol. i., p. 94. 

J " International Encyclopaedia of Surgery," vol. v., pp. 94, 95. 



FRACTURES OF THE CRANIUM. 67 

pie depressed fracture. This author further says that his own 
experience has taught him that trephining is not a dangerous 
operation, and that more patients die from complications, that 
might have been prevented by timely operation, than from the 
removal of a disk of healthy bone. 

Dr. R. W. Amidon of New York has collected 115 cases of 
trephining and kindred operations occurring since 1879. 
These operations were done for various causes, and were un- 
selected by Dr. Amidon; nor did he confine himself to cases 
treated antiseptically.* Of these 115 unselected cases, 29 
died; but of these 25 presented, at the time of operation, symp- 
toms endangering life, leaving therefore but four cases in 
which the fatal issue could be attributed to the operation. 
This gives a mortality of a little over three per cent, to the 
operation. He announces his reasons for considering the 25 
deaths as not attributable to operation in the following words: 
" In six cases, symptoms of abscess of the brain declared them- 
selves before the operation was performed. In five a men- 
ingitis existed at the time of operation. In four cases shock 
caused death; two died of hemorrhage from a branch of the 
middle meningeal artery (not wounded in the operation) ; one 
died of hemorrhage from the middle cerebral artery, severed 
by a stab wound of the head; one died of hemorrhage from a 
lacerated longitudinal sinus; one of galloping consumption, 
which was hereditary; one of pneumonia; one of extensive 
laceration of the brain; one of opium poisoning; and three I 
accept, on authority of the physician reporting them, as not 
dying from the effects of the operation." f 

Yeo t trephined twenty-six monkeys under antiseptic pre- 
cautions, and had only one death attributable to intracranial 
inflammation, though six other deaths from exposure to cold 

* Annals of Surgery, St. Louis, March, 1885, p. 205 ; see also, his pre- 
vious paper, Medical News, June 21, 1884 

f This list accounts for the death of 26 instead of 25 patients, and ap- 
parently contains an error. — J. B. R. 

\ British Medical Journal, May 14, 1881, p. 763. 



68 THE MODERN TREATMENT OF FRACTURES. 

weather, chloroform poisoning, or hemorrhage occurred 
among his cases. In some of the animals portions of the brain 
were excised. Of other monkeys trephined without antisep- 
tic precautions all died. 

Much stress has been laid by some writers on the danger of 
wounding the membranes and brain with the trephine. "With 
a conical trephine or the burr of the surgical engine, as 
recommended by Doit and by myself,* there is no danger of 
this. Even if such an accident should occur to the mem- 
branes, it is, in my opinion, of very minor importance unless 
the damage is much greater than could occur except by gross 
carelessness. Dr. Gunn disapproves of the use of the mallet 
and chisel, because he believes that the repeated shocks to the 
brain may prove injurious to the nerve-tissue. f For remov- 
ing large or irregular areas of bone, the fiat burr of the surgi- 
cal engine is certainly much more accurate and desirable. 
Osteoplastic resection with chisel, electric engine, or wire saw- 
gives easy access to the brain. 

I have compared trephining with amputation through the 
metacarpal bone, because in both operations there is expos- 
ure of cancellated bone structure. I do not know that the 
mortality of such finger amputations has been accurately com- 
puted, but is certainly regarded by all as slight. It is seldom 
that patients are confined to the house after such amputations. 
Trephining in itself is, I am convinced, little if any more 
hazardous. I believe that one of us trephined to-day might, 
if it were necessary, go home without incurring any great risk 
to life; though I would not advise such a procedure. Ampu- 
tation of the finger may be followed by erysipelas, septi- 
caemia, or death: so may trephining, but it is not to be ex- 
pected. The mortality of amputations of the thumb and 
fingers is, according to Ashhurst,! 3.3 per cent. This un- 

* Buffalo Medical aa.l Surgical Journal, xix., 1879-80, p. 4T5 ; Phila- 
delphia Medical Times, 1881-82, xii , 206. 

f " Transactions of the American Surgical Association," vol. i., p. 88. 

{"International Encyclopaedia of Surgery," vol. i., p. 637. 



FRACTURES OF THE CRANIUM. 69 

doubtedly is less than the mortality of amputations through 
the metacarpus, because amputations of distal phalanges, 
which are almost without risk, are of course included. The 
same writer gives partial amputations of the hand a mortality 
of 6.6 per cent. If, therefore, we estimate amputation of a 
single finger through the metacarpal bone as having a mor- 
tality of 4 or 5 per cent., it will probably be nearly correct. 
According to the figures of Amidon, given above, trephining 
is actually much less dangerous to life than this. 

In the majority of cranial fractures, the inner table is more 
extensively shattered and splintered than the outer table. 

Many experimental fractures made in the dissecting-room, 
and observation of cases in the practice of myself and of others, 




Fig. 7. 
Accentuated fracture showing a slight indentation in external table. 

teach me that extensive shattering of the inner table, with 
only a moderate amount of fracturing of the external table, 
is of frequent occurrence in other as well as in punctured frac- 
tures. I admit that the condition in the cadaver, preserved 
by zinc chloride, with its shrunken brain, is different from 
that in the living; but there is much evidence of the same 
splintering to be found in the study of accidental and homo- 
cidal cranial fractures. This is in accordance with the well- 



70 THE MODERN TREATMENT OF FRACTURES. 

known mechanical law, that compressing force applied to the 
outside of a surface, as are undoubtedly most fracturing forces 
applied to the skull, tends to produce more extensive breaking 
of the inner surface. This is especially so in all localized 
blows. Punctured fractures have long been treated by early 
trephining, to avert encephalitis. For the same reason I 
recommend resort to trephining even in more diffused and less 
accentuated fractures. It is to prevent inflammatory se- 




Fig. 8. 

Accentuated fracture showing marked depression of internal 
table revealed by trephining. Same case as Fig. 7. 

quences due to splinters forced into the membranes and brain 
and to avert a consecutive occurrence of epilepsy and insanity, 
that the operation should be performed; not because of the 
fear that symptoms of compression of the brain may arise, 
nor because necrosis of detached portions of bone may occur. 
Sometimes there is no fissure in the outer table, though the 
inner table is extensively broken and depressed. Twenty 
such cases are reported as having occurred during the late Civil 
War.* All of these patients died from intracranial inflam- 

* " Medical and Surgical History Rebellion," Pt. I., Surgical Volume, p. 
150. 



FRACTURES OF THE CRANIUM. 71 

niation except one, in which the splintered portion of the 
inner table was removed as a sequestrum.* I show you a 
piece of skull removed from a patient who recently died under 
my care. He was struck with a pitcher, Avhich caused a 
small scalp Avound through which my finger-tip felt rough 
bone. I enlarged the incision, came upon a very rough sur- 
face, due to unusual irregularity of the lambdoidal suture, 
with small Wormian bones, and found only a small dent or 
fissure looking much like the entrance of a vein. I deter- 
mined to do exploratory trephining because of the nature of 
the vulnerating force. Dr. George Dock, under my direction, 
cut out a disk of bone close to the external dent, at the po- 
sition which was thought would give best access to any splin- 
ters. Nothing was found but a small fissure crossing the 
inner surface of the disk. A probe slipped between the inner 
table and the dura disclosed no irregularity; therefore no fur- 
ther operative steps were taken. A portion of the inner table 
left in the bottom of the trephine-hole was undisturbed be- 
cause it was smooth. The patient died in about forty-two 
hours of delirium tremens. Dr. H. F. Formad, the patholo- 
gist, found no inflammation of brain or meninges, but intense 
oedema of the brain and membranes, and at the inquest swore 
that death occurred from alcoholic delirium. The section of 
bone presented to you shows a marked depression of the table 
due to a T-shaped fracture under the seat of the external dent, 
beneath which was a small clot upon the dura mater. The top 
line of the T, which in the figure is vertical, is one and one- 
quarter inch long. The cleansed bone shows a semi-ellipti- 
cal fissure of the external table encircling the slight dent. 
If this patient had lived, he would have been very liable, I 
think, to epilepsy or insanity. Only a few weeks ago I saw, in 
consultation with Dr. Charles K. Mills, a man of twenty-two 
years who was suffering with marked mental impairment occur- 

* Prescott, Hewett, and Lidell have furnished other statistics of such cases. 
Holmes' " System of Surgery," American edition, 1881, vol. i. , p. 636. 



< '1 THE MODERN TREATMENT OF FRACTURES. 

ring as he and his brother said, subsequent to a fracture of the 
skull received about four years previously. Reference to the 
notes of the Pennsylvania Hospital, in which he had been 
treated, showed that he had been admitted for a compound 
depressed fracture of the skull, which was so slightly marked 
that operation was not deemed necessary. It is probable that 
his mental impairment was due to a depression similar to that 
seen in this specimen. It was my intention to trephine in this 
case of mental failure if further investigation of his con- 
dition by Dr. Mills conclusively traced the aberration to the 
injury. Unfortunately, the patient passed out of our control 
by returning to his country home before I had a second op- 
portunity of examination. 

I feel sure that the element of danger in skull fractures is 
this splintering of the inner table; and I differ most decidedly 
from those who esteem it of comparatively little importance. 
Its danger in those abruptly depressed fractures, called punc- 
tured fractures, has been quite generally recognized; but its 
great frequency and risk in other forms of fracture are still 
not sufficiently emphasized by all authorities. Ashhurst, in 
the edition of his " Surgery " published in 1882,* said, in 
speaking . of simple depressed fractures. " I have never 
seen a case of this kind in which I thought the use of 
the trephine justifiable, nor an autopsy which showed 
that the operation could possibly have saved life." 
In compound depressed impacted fractures he would 
not advise operation, " even if symptoms of compres- 
sion were present.'' He goes on to say that the tre- 
phine " is not to be used with the idea of relieving compres- 
sion, nor with the idea that there is any special virtue in the 
operation to prevent encephalitis.'' In punctured fracture the 
same distinguished surgeon thinks the trephine may be neces- 
sary to slightly enlarge the opening in the skull to remove 
the spicules which are apt to be broken from the more ex- 
* Pp. 325, 326. 



FKACTUKES OF THE CKANIUM. 73 

tensively involved internal plate; but says, "It is better to 
leave imbedded in the brain, a foreign body, or even a frag- 
ment of bone, than to add to existing irritation by reckless 
attempts at its removal." 

Perhaps Dr. Ashhurst has changed his views within the last 
few years. If he has not, I must disagree with him on this 
subject, except in the opinion that reckless surgery is always 
unjustifiable. His definition of what constitutes reckless sur- 
gery may differ from mine. 

Many writers, while admitting the probability of greater 
damage to the inner table, do not give its disastrous conse- 
quence sufficient stress. Briggs,* however, truly says that 
the great danger in depressed fracture is not compression, but 
inflammation set up by displaced fragments of bone. Dr. 
Sands says t that advocacy of early trephining, on the ground 
that loose pieces of bone in simple comminuted fracture will 
probably become necrosed and set up fatal intracranial in- 
flammation, is improper. I believe that few advocates of 
early trephining give necrosis as a reason for their belief. Ne- 
crosis is not, but encephalitis is, very liable to occur. 

Dr. Sands also believes that the apprehensions felt by those 
who advocate preventive trephining in closed depressed frac- 
ture without head symptoms, with the object of removing 
sharp fragments of the inner table, are scarcely justified by 
observation. These extensive osseous lesions are, in his opin- 
ion, often recovered from without surgical interference. He 
states + that immediate resort to the ti'ephine is imperatively 
required, however, in fractures of limited extent, and in those 
in which there is reason to think, from their situation or the 
occurrence of monoplegia, monospasm, or hemiplegia, that a 
splinter has penetrated the motor area of the cortex. Tre- 
phining is also demanded, in Dr. Sand's opinion, when com- 

* " Annals of Anatomy and Surgery," vol. vii., p. 69. 

f Ibid.', vol. viii., 1883, pp. 101-103. 

% "Annals of Anatomy and Surgery," vol. viii., 1883, p. 106. 



74 THE MODERN TREATMENT OF FRACTURES. 

pression of the brain is due to blood between the dura and 
cranium. 

Perforation of the cranium is to be adopted as an explora- 
tory measure almost as often as it is demanded for therapeutic 
reasons. 

I have shown that the occurrence of fatal encephalitis is 
frequently due to spiculation of the inner table, and that 
spiculation or extensive shattering of the inner table is com- 
mon in limited fractures of the external table. Hence it fol- 
lows that exploratory perforation of the cranium is justifiable 
in all cases where the nature of the impinging force, or the 
appearance of the external table, renders spiculation of the 
inner table probable, provided that less danger to life and 
health is inherent in perforation than in the probable spalla- 
tion. I have already asserted my belief in, and given rea- 
sons for, a low mortality risk of perforation. I am of the 
opinion that fractures of the cranial vault, produced by such 
general application of force as occurs when a man falls from 
a great height upon his head are less frequent than fractxires 
by direct and comparatively localized blows, such as occur 
from ordinary missiles, bullets, and falls from low elevations. 
These latter are those which tend to produce internal spicula- 
tion. Hence I am driven to the conclusion that exploratory 
perforation to determine the absence or presence of internal 
spiculation is often demanded by the uncertainty of the in- 
visible condition. Without a knowledge of the true state of 
affairs treatment is empirical; and the risk to subsequent men- 
tal health or to life is too great to permit reliance on em- 
pirical treatment, when a knowledge of the true condition is 
obtainable with the slight danger that pertains to antiseptic 
trephining. 

"Whenever the fracture, whether originally an open one or 
so made by an incision, presents the possibility of the inner 
table being detached and splintered more extensively than 
the outer, I should be inclined to advise perforation. In other 



FRACTURES OF THE CRANIUM. 7 

words, I would cut the scalp to see the condition of the outer 
table, and I would cut the bone to see the condition of the 
inner table, in every case where the risk of obscure knowledge 
is greater than the risk of divided scalp and perforated bone. 

The tendency to procrastination in such matters has de- 
stroyed many lives. Nancrede * recommends early pre- 
ventive trephining strongly, because, after encephalitis has 
once begun, trephining does not remove the inflammation, but 
merely one source of irritation without influencing the exist- 
ence of the inflammatory process which has been aroused. 
His statistics show the mortality of the operation, after symp- 
toms of brain disease have arisen, to be much more than twice 
as great as in preventive operations — the figures are 52.8 per 
cent, and 22 per cent. He further says, that, although the 
operation should be done early, it is never too late in neglected 
cases to make the attempt; for an abscess may be found and 
evacuated with the result of saving life. Stimson f says that 
the percentage of recovery in early operative interference is 
actually high compared with tardy operations; and cites in- 
structive cases to prove that his opinion is correct. "Wound 
of the longitudinal sinus and removal of about three square 
inches of bone were no bar to recovery in a case which he 
treated by immediate trephining, though no brain symptoms 
except stunning were present. 

In discussing the treatment of cranial fractures I shall ask 
myself four questions: 

1. What conditions demand incision of the scalp? 

2. What conditions render incision of the scalp un- 
justifiable? 

3. What conditions demand perforation of the skull? 

4. What conditions render perforation of the skull un- 
justifiable? 

These queries are best answered by the tabulated statement 

* "International Encyclopaedia of Surgery," vol. v., p. 95. 

f "Treatise on Fractures," p. 248. 



76 THE MODERN TREATMENT OF FRACTURES. 

which follows. I admit that the line of treatment advocated 
is more heroic than that generally taught, but it has been ac- 
cepted only after careful consideration of the reasoning of 
those who hold the opinion contrary to my own. Every case 
must be individually studied, and the patient's chances of 
death, of life with subsequent epilepsy or insanity, or of return 
to perfect health, carefully weighed; but for a working rule 
to guide the student and practitioner I think experience will 
show that the indications given in the table are correct. Tre- 
phining, properly performed, is in itself so free from danger 
that in a doubtful ease the patient had better be trephined 
than allowed to ran the risk of death, epilepsy, or insanity. 
Legouest was very nearly right when he . said : " Whenever 
there is a doubt whether trephining should be done, this doubt 
is probably an indication that operation should be per- 
formed." * 

Syllabus of the Treatment of Fractures of the Cranium. 
Closed Fissured Fractures. 

1. Xo evident depression, no brain symptoms. No 
operation. 

2. No evident depression, with brain symptoms. Incise 
scalp and trephine. 

3. With evident depression, no brain symptoms. Incise 
scalp and probably trephine. 

4. With evident depression, with brain symptoms. Incise 
scalp and trephine. 

Closed Comminuted Fractures. 

5. JSTo evident depression, no brain symptoms. Incise 
scalp and probably trephine. 

6. No evident depression, with brain symptoms. Incise 
scalp and trephine. 

* Lucas-Cliampionniere, " Trepanation guidee per les localisation cere- 
brates," p. 23. 



FRACTURES OF THE CRANIUM. 77 

7. With evident depression, no brain symptoms. Incise 
scalp and trephine. 

8. With evident depression, with brain symptoms. Incise 
scalp and trephine. 

Open Fissured Fractures. 

9. ~No evident depression, no brain symptoms. ~No opera- 
tion, but treat wound. 

10. 'No evident depression, with brain symptoms. Tre- 
phine. 

11. With evident depression, no brain symptoms. Tre- 
phine. 

12. With evident depression, with brain symptoms. Tre- 
phine. 

Open Comminuted Fractures. 

13. No evident depression, with brain symptoms. Tre- 
phine. 

14. No evident depression, with brain symptoms. Tre- 
phine. 

15. With evident depression, no brain symptoms. Tre- 
phine. 

16. With evident depression, with brain symptoms. Tre- 
phine. 

Punctured and Gunshot Fractures. 

17. In all cases and under all circumstances. Trephine. 

The operation, when decided upon, should be performed 
at once, or certainly not delayed more than a few hours. 

All cases, whether trephined or not, should be treated as 
cases of incipient inflammation of the brain. 



SUBCUTANEOUS NAILING, EXPLORATORY INCISION AND 
THE EXTENDED ELBOW IN CONDYLOID FRACTURES OF 
THE HUMERUS. 

It is my desire to present in a succinct manner such per- 
sonal opinions as will lead to a similar expression of views from 
other surgeons. That which I shall contribute to the debate 
will advocate no very striking novelty in procedure and will 
record no conspicuous discovery in surgical pathology. It 
will simply show the conclusions in regard to certain problems 
in practical surgery at which I have arrived from thoughtful 
consideration of personal experience, combined with a limited 
amount of experimental work and more or less familiarity with 
surgical literature. 

These conclusions I shall for the sake of brevity and clear- 
ness formulate as definite propositions: 

1. Anchylosis of the elbow- joint after condyloid fractures 
is usually due to imperfect reduction of fragments or in- 
complete restitution of structural relations. 

The interference with mobility largely results from distinct 
alterations in shape of the articulating surfaces, due to the 
incorrect coaptation, though overgrowth of bone from 
stripped-up periosteum, and ossific depositions in the sero-liga- 
mentous capsule aid in its production. Experience seems 
to show that mobility of the joint is as a rule promptly re- 
gained when the play of the olecranon and coronoid processes 
around the trochlear surface is not obstructed by bony dis- 
placement or new deposits. In persons of an arthritic dia- 
thesis intra-articular and par-articular adhesions may undoubt- 
edly restrict motion, but these are not the usual cause of 



CONDYLOID FRACTURES OF THE HUMERUS. 79 

anchylosis, after fractures of the humeral condyles. To hem- 
orrahagic effusions into the joint have been attributed adhe- 
sions of newly formed connective tissue and thickenings of the 
synovial membrane; but these causes of anchylosis are rela- 
tively unimportant. 

Powers of Denver has reported * an interesting instance of 
anchylosis in extension, after fracture at the elbow, in which 
exploration disclosed a broken-off coronoid process situated 
behind the joint. This was removed, part of the broken con- 
dyle chiseled away and the patient finally given almost perfect 
mobility of the elbow. This case is valuable in showing that 
displaced bone causes anchylosis; and that incision at the time 
of the receipt of the lesion would probably have permitted 
restoration of bony contour and prompt recovery of functional 
activity. 

2. Conservation of the normal angle between the axes of the 
humerus and ulna is desirable. 

Much attention has been given in recent years to the possi- 
bility of fractures of the lower end of the humerus causing 
cubitus varus or " gunstock deformity " of the arm, thereby 
interfering with the so-called " carrying function " ' of the 
upper limb. This deformity has been supposed to result from 
ascent of a detached internal condyle; descent or rotation for- 
wards and inwards of a detached external condyle; and rota- 
tion forwards and towards the middle line of the body of the 
condyloid mass, after transverse or comminuted fracture. 

H. L. Smith of Boston, Mass., believes f that this deformity 
is not apt to occur from fracture of a single condyle, but 
after a break traversing the entire width of the humerus; 
and he considers that the deformity has been given unneces- 
sary importance in the determination of the best posture in 
which to treat fractures at the lower end of the arm bone. 
Stimson of New York, on the other hand, has asserted $ 
* Medical Record, 1896, vol. i., p. 615. 

f Boston Medical and Surgical Journal, October 18, 1894, p. 389. 
X " Transactions American Surgical Association," ix., 1891, p. 270. 



80 THE MODERN TREATMENT OF FRACTURES. 

that displacement of a condyle, not exceeding one- 
quarter inch or one-eighth inch in amount, may effect 
a change in the humero-ulnar angle. The analogous 
displacements produced intentionally, by Ogston's con- 
dyloid and Macewen's supracondyioid osteotomy, for the 
relief of knock-knee, suffice to explain the mechanical fac- 
tors in the production of gunstock deformity of the arm and 
convince me that fracture of one or of both condyles may 
produce the unsightly deformity. This I have proved by 
experimental fracture detaching the internal condyle and 
other fractures causing more complicated bony lesions of the 
lower end of the humerus. I am not so certain of the de- 
formity being readily produced by descent of the external 
condyle, when it alone is separated from the shaft of the bone. 

It must be recognized that the humero-ulnar angle differs 
greatly in individuals. I have found it less conspicuous in 
children and women than in men; and believe it to be most 
marked in those of well-developed muscular power. Smith 
has found it to vary between — 5° and +30°, and states that 
even in the same person the two uninjured arms may differ 
as much as 10° to 15°. He also found that the width of the 
condyloid portion of normal arms differed on the two sides of 
the same person. The average variation in 50 cases measured 
was 3.1 mm. He investigated 75 cases of united fracture of 
the elbow, treated according to traditional methods, to find 
that the average difference on the two sides was 5.5 mm. The 
increased width was, if I correctly understand him, on the side 
injured. He makes the important statement that in 20 cases 
treated by acute flexion, the average difference in width after 
union was 1 mm. and that in these same cases the carrying 
angle was unchanged in 40 per cent. In the 75 cases treated 
by various persons in the ordinary ways the carrying angle was 
unaltered in 10 per cent. 

It is probably true that the conversion of the humero-ulnar 
angle into a straight line or its change to an angle in the op- 



CONDYLOID FRArrrilKS OF THE HUMERUS. 



81 



posite direction lias little effect on the wage-earning capacity 
of the patient; but it certainly produces an unsightly de- 
formity and impairs the symmetry and integrity of the human 
mechanism. It does not of itself interfere with mobility of 




Gunstock Deformity of Left Elbow after Fracture of Lower 
End of Humerus. 

the joint. I recently saw a young lady who about fifteen 
years ago, when a child, broke the condyloid portion of the left 
humerus. I took part in the treatment of the injury, which 
was by means of a rectangular trough-shaped posterior splint. 
She has marked gunstock deformity, as a result of the defec- 



82 THE MODERN TREATMENT OF FRACTURES. 

tire treatment, but has perfect mobility of the joint. The 
hand is of course brought nearer the thigh when the linib 
hangs vertically, but this defect brings no special inconven- 
ience. It might perhaps be a disadvantage to a woman in the 
lower walks of life, who was compelled to carry burdens in 
the dependent hand. I refer to this patient, because it was 
my dismay at the deformity remaining after the treatment 
adopted that first forcibly directed my attention to the disad- 
vantage incident to right-angle flexion in the management of 
these bony lesions: and because she by chance came into my 
office after many years' absence, while I was preparing this 
paper. 

It is an acknowledged duty of the surgeon to restore after 
injuries the anatomical symmetry as well as the functional 
usefulness. Hence no extended argument is necessary to 
prove that it is best to adopt that Hue of treatment which will 
attain both ends. Retention of the normal humero-uhnar 
angle of a broken elbow is therefore not only desirable for 
cosmetic reasons, but is demanded by anatomical and surgical 
considerations. 

3. Fixation is satisfactorily obtained by nailing the frag- 
ments together with long nails driven through the sl'in. 

The occasional deformity and limitation of motion, result- 
ing from fractures of the condyloid portion of the humerus, 
are doubtless due not only to incomplete reduction of the 
broken bone; but to an imperfect fixation, which has allowed 
the properly adjusted fragments to slip again into abnormal 
relations. Stimson is probably not alone in his belief * that 
" in intercondyloid fracture with marked separation, there is 
no practicable means surely to maintain reduction." He says 
further that the impossibility of direct control of the frag- 
ments, the contraction of muscles, and the pressure of fascia 
combine to make the result largely a matter of chance. This 
opinion was confirmed, he states, by seeing and feeling in open 
* " Transactions American Surgical Association," ix.. 1891, p. 272. 



CONDYLOID FRACTURES OF THE HUMERUS. 



S3 



fractures the difficulty caused by the shiftings of the frag- 
ments. 




Gunstock Deformity of Left Elbow after Fracture of Lower 
End of Humerus. 



I have been making some experimental observations during 
recent months on the use of nails for direct fixation of frac- 



^4 



THE MODERN TREATMENT uF FRACTURES. 



tures: having been led to the investigation by my success at 
the Philadelphia Polyclinic Hospital in nailing together the 
fragments of a metacarpal bone. I have found that frac- 
tures of the condyles of the humerus, made in the cadaver, 

can be satisfactorily fixed after reduction by driving wire nails 




Fig. 11. 

Experimental fracture of internal condyle (made with osteotome!. 
Fragments kept in position with wire nail driven through skin. Skiagraph 
taken with dorsum on photographic plate. 

through the skin into the bone and across the lines of separa- 
tion. 

The accompanying skiagraphs show the method better than 
a verbal description. 

I became convinced by this experimental work of the effi- 
ciency of fixation by means of -lender nails, and of the wis- 



CONDYLOID FRACTURES OF THE HUMERUS. 



85 



dom of adopting the procedure in the comparatively few 
severe fractures of the humeral condyles needing direct fixa- 
tion. I have had, however, no personal clinical experience 
of such operative treatment in elbow injuries; and my opinion 




Fig. 12. 

Experimental V-shaped fracture of condyles (made with osteotome). 
Fragments fixed with wire nail driven through skin. Skiagraph taken 
with anterior surface on photographic plate. 



was based on inductive reasoning alone and the use of similar 
means in resection and osteotomy. 

A few days since I came upon Stimson's statement that in 
an open fracture of the condyles he had " felt constrained to 
pass a long steel pin transversely through both condyles and 
the long projecting end of the upper fragment, for in no other 



86 



THE MODERN TREATMENT OF FRACTURES. 



way could they be kept in apposition." * I had undoubtedly 
seen this report before, but had forgotten it. Stimson does 




a 5 

2 = 
o _ 
o .— 

1> 



not give the result, but I can see no reason to doubt that the 

coaptation continued satisfactory. If the operative field was 

* "Transactions American Surgical Association," ix. ( 1891, p. 272. 



CONDYLOID FRACTURES OF THE HUMERUS. 8< 

free, and kept free, of septic complications, the result ought to 
have been good. 

I have had made special " fracture nails " of tempered 
steel, with a drill-shaped point and a long, square head. 



-71" 




Fig. 14. 
Fracture Nails and Drill. 

These are readily pushed through the skin, muscles and com- 
pact exterior of the bone by means of a handle which fits the 
head. The handle is then detached and the nails are driven 
into the deeper portions of bone with a hammer. After two, 
three, or four weeks the nails should be pulled out by the claw- 




Fro. 15. 
Hammer Forceps. 

like forceps. For convenience I have had a hammer-head 
made upon one side of the forceps. 

During the driving of the nail or nails the fragments 
already adjusted are held by the fingers of the operator or as- 
sistant; and after fixation is accomplished an aseptic dressing 



88 THE MODERN TREATMENT OF FRACTURES. 

and a light splint of wood, metal, paper, or gypsum are ap- 
plied. 

Ordinary wire nail? and a hammer may be used with satis- 
faction, but the want of temper and point makes them rather 
less convenient. 

If the nail first inserted does not effectively fix the pieces 
of broken bone, it should be withdrawn and re-inserted, or 
one or two additional nails should be used. The placing of 
the nails will be found much more easy in open than in closed 
fractures; and will require more skill and patience in com- 
minuted fractures than in those in which there are but two 
fragments. 

There will be but a limited number of fractures in which 
this operation is demanded, but it will, I believe, be found 
valuable in a certain proportion of cases. Xo one should at- 
tempt the operation unless he is a believer in asepsis and a 
conscientious exponent of modern aseptic surgical methods. 
Careless or incomplete asepsis is not permissible. It is as rep- 
rehensible as in abdominal or cerebral surgery. 

4. Previous skiagraphs may be needed to aid in determin- 
ing the point at which the nails should be introduced and the 
direction in which they arc to be driven. 

If the exact direction of the fracture lines cannot be deter- 
mined by palpation and manipulation, the use of the fluoro- 
seope or better the study of skiagraphs will often permit the 
surgeon to determine how best to nail the fragments together. 
If sufficiently definite information cannot be obtained by 
palpation, manipulation, and the use of Roentgen rays, ex- 
ploratory incision is the safest course in severe injuries of ob- 
scure character. 

5. Obscure or severe fractures may demand exploratory 
incision for replacement of fragments and prevention of 
anchylosis. Such incisions are not employed as often as they 
should ho. 

Aseptic incision of joints, being in competent hands prac- 



CONDYLOID FRACTURES OF THE HUMERUS. 89 

tically free from risk to life, is demanded in a certain number 
of elbow fractures, because the anatomical integrity of the 
joint and its functional usefulness are jeopardized by the sur- 
geon's ignorance of the lesion and his consequent inability to 
repair the structural damage. After incision, the fragments 
can be accurately adjusted, the torn periosteum replaced; 
muscles, fascias and nerves disentangled from undesirable 
positions between the bone fragments, and sutured if lacer- 
ated; and fixation of the fragments consummated. It is 
probable also that cure will be hastened and pain lessened by 
the removal of bloodclots and the leakage of synovial fluid and 
inflammatory exudate, permitted by the incision; and that fat 
embolism and non-union will be less likely to occur. 

The well-informed modern surgeon, who must know the 
safety of aseptic operations, should not hesitate to adopt ex- 
ploratory incision in appropriate cases. The patient with a 
bad fracture of the elbow lias an intrinsic right to the benefit 
derivable from incision in competent aseptic hands. 

6. The best route for this exploratory investigation is 
through the groove between the biceps and lorn) supinator. 

My investigations at the Laboratory of the Philadelphia 
Polyclinic have led me to adopt, for exploration of the con- 
dition of the lower end of the humerus, a curved incision on 
the outer portion of the anterior aspect of the elbow joint, 
Avhich turns up a flap exposing the biceps and long supinator. 
The cut begins at a point about ft cm. above the tip of the 
external condyle and ends about cm. below the tip of the 
condyle. It is about 15 cm. long and convex towards the 
middle line of the arm with the center of the curve correspond- 
ing with the point midway between the condyle-. \Vhen this 
cellulo-cutaneous flap has been raised, the inter-muscular 
groove between the biceps and long supinator is seen. Blunt 
dissection down this pathway discloses the front of the 
humerus and the anterior ligamentous covering of the joint. 
The muscular-spiral nerve will perhaps be seen, but is easily 



THE MODERN TREATMENT <'F FRACTURES. 

preserved from injury. Tlie entire width of the hone and 
joint is rendered accessible to touch and inspection. 

7. The extended position of the elbow is less likely than 

right-angled -flexion of the joint to be followed by impairment 

of the normal humero-ulnar angle, which gives the u carrying 

function upper extremity; and it is therefore the 

lyloid fractures of ordinary severity. 

It has been my practice to treat these fractures with the 
elbow extended and to carefully compare the injured with the 
sound limb, in order to preserve by my splints the humero- 
ulnar angle. I reduce the fragments, compare the two arms. 
and apply a splint of wood or of gauze and gypsuni - : 
the joint not quite fully extended. Full extension is more apt 
to be irksome to the patient : and it is a wise precaution to run 
no risk of displacing the fragments by hyperextension of the 
injured joint. A thin narrow board is usually laid on the 
front of the normal arm and the direction of the axes of the 
humerus and ulna marked on it. A penknife is then em- 
ployed to whittle the board into proper shape, and, by revers- 
ing it. a proper splint is made for the broken bone. The 
splint is padded, a little cotton laid in the flexure rf 1 
and bandages used to hold the splint in position. A gyj - 
splint molded to the arm is more elegant, but is not alway- 50 
conveniently obtained. 

The extended elbow in these fractures has been adv 
for various reasons. It has been said that it enables th - - 
geon to appreciate more readily any change in the deviation of 
axes than the right-angled position, which crowds up tih sofl 
tissues in front of the joint and obscures the position I 
fragments. The angular deformity, to be avoided, has 
attributed to the displacing influence of the triceps, which is 
relaxed by employing the extended posture. If the extended 
elbow is combined with supination of the radius the tri 
also considerably relaxed. The position advocated - . 
therefore to relax the important displacing muscles, with the 



CONDYLOID FRACTURES OF THE HUMERUS. 91 

exception of the anterior brachial. Some writers allege that 
the displacement of the condyles and the destruction of the 
" carrying function " by right-angle splints are due to the fact 
that the radius lies at a higher level than the ulna, and that 
the splint and bandaging tend to bring them on the same level, 
thereby raising the internal condyle or depressing the external. 
I am inclined to believe from experimental evidence on the 
cadaver, that this is to a certain extent true, though too much 
importance may heretofore have been accorded to it by us who 
advocate the extended elbow. 

Strong clinical evidence of the worth of the extended 
posture is the assertion * of Thompson of Washington, who 
was able in two open fractures to keep the fragments in posi- 
tion when the arm was extended, but found that they were 
displaced if he attempted to keep them in position with the 
elbow at right angle. Taylor of San Francisco reports f a 
similar experience with a closed fracture. 

It is unnecessary to intimate to this audience that Liston 
treated elbow fractures in the straight position, if I am correct 
in my belief. 

Thomas of Liverpool, Jones of Liverpool, as well as Dulles t 
of Philadelphia; LL L. Smith § of Boston, and Bruce || of 
Dingwall, Scotland, recommend acute flexion in the man- 
agement of these injuries; but I have never tried it, though 
some of my colleagues at the Philadelphia Polyclinic have 
had, I understand, satisfaction in its employ. 

* "Transactions American Surgical Association," x., 1892, p. 58. 
f " Transactions American Surgical Association," x., 1892, p. 65. 
X Boston Medical and Surgical Journal, August 30, 1894. 
§ Boston Medical and Surgical Journals October 25, 1894, and July 4. 
1895. 

1 British Medical Journal, 1896, ii., p. 1201. 



XI. 

TREATMENT OF FRACTURES OF THE LOWER END OF THE 
HUMERUS AND OF THE BASE OF THE RADIUS. 

The frequency of fractures at the lower end of the humerus 
and at the base of the radius and the necessity of maintaining 
functional integrity of the joints of the upper extremity, make 
the consideration of such injuries of primary importance. 
The desirability of an accepted and usually practiced method 
of treatment for these fractures will be unquestioned: while 
the value of establishing such rules of practice is fully recog- 
nized by all interested in surgical jurisprudence. 

The great diversity of opinion exhibited by the members of 
this Association last year, when the subject of elbow injuries 
was introduced by Dr. L. A. Stimson, was a revelation to me. 
I had, up to that time, believed that my own views, derived 
from the study of surgical literature and clinical cases, were 
not very different from those of other surgeons. Hence, I 
was somewhat unprepared for the remarks of many of the 
speakers on that occasion. 

A pretty thorough examination of the text-books in the 
hands of the practitioners and students of this country and an 
investigation of some of the writings of foreign surgeons have 
led me to believe that much bad surgery is taught and prac- 
ticed. This state of affairs must be due to ignorance of 
recent advances in surgical pathology or to an indisposition to 
accept statements and methods of treatment which appear to 
me to appeal very strongly to surgical experience and intelli- 
gence. As an illustration I quote from a recent work of M. 
Amiand Despres, published in 1S90. The author, in speak- 
ing of fractures at the lower end of the radius, says : * " I am 
* " Treatise oq Fractures," translated by Dr. E. P. Hurd, p. 4. 



FRACTURES OF HUMERUS AND RADIUS. 93 

of Nekton's opinion that the reduction is not necessary: the 
apparatus when well applied reduces the fracture by degrees 
and without pain." He, moreover, does not apply the splints 
until from twenty-four to thirty-six hours after the injury, but 
uses up to that time warm fomentations or cataplasms. Such 
a method of treatment seems to me so totally opposed to surgi- 
cal principles and the advice of such a dangerous character to 
give students that any discussion which will neutralize the 
effect of this author's words cannot be without value. 

Again, I find in Dr. Henry R. Wharton's valuable treatise 
on " Minor Surgery and Bandaging," published in 1891,* the 
direction given that, before applying any splint in fractures 
of the lower end of the humerus, " it is well in many cases 
to apply over the region of the fracture several folds of lint 
saturated with lead water and laudanum, and to cover this 
dressing with wax paper or rubber tissue, to diminish as far as 
possible the swelling which is very marked after these in- 
juries." My own belief is very strong that such dressing is 
not only useless but harmful; because the application of these 
poultices over the injured limb often gives rise to the occur- 
rence of cutaneous vesication in the inflamed region. Evapo- 
ration of the lotion is prevented by the rubber tissue or wax 
paper and the encouragement of serous exudate beneath the 
cuticule is not infrequently followed by large blebs. Such 
applications are never required in fractures, since the swell- 
ing and oedema, due to the aseptic traumatic inflammation, 
rapidly subside if the fragments are properly adjusted and 
kept at rest. I have a continual struggle with young hospital 
residents to prevent their following this pernicious advice, 
which appears to be taught by more than one lecturer. In 
cases where the swelling and oedema will not subside by co- 
aptation of the fragments and rest, more active surgical 
interference than applications of lead water and laudanum is 
required. 

The unfortunate tendency to use complicated fracture dress- 
*P. 325. 



94 THE MODERN TREATMENT OF FRACTURES. 

ings, which obtained in the early history of surgery, still re- 
mains to be overthrown by the continued advocacy of 
mechanical simplicity. Most of these appliances appear to 
have been invented by those more interested in the construc- 
tion of machinery than in a simple solution of the mechanical 
problems presented by osseous injuries. The application of 
these complicated dressings is nearly always expensive and 
uncomfortable to the patient, confusing to the average practi- 
tioner, and unintelligible to the student. Their use, more- 
over, tends to direct the attention of the surgeon to the kind 
of apparatus rather than to the conditions presented by the 
special injury under his care. Xo better illustration of this 
tendency to devise unnecessary appliances for fractures is 
needed than this drawing of an apparatus of Professor Bar- 
denheuer for fractures of the lower end of the radius. You 
see the patient confined to bed, on the framework of which are 
fastened six pulleys, through which five cords with weights 
make traction on as many different parts of the arm and hand. 
You will be surprised perhaps when I tell you that this device 
of the Inquisition is described in his book published in Stutt- 
gart in 1891.* The other splints and dressings represented 
and advocated by this writer in like manner strike the practical 
surgeon with amazement. If it were not for the indisputable 
evidence of the title page, the book might be regarded as the 
work of a mediaeval author. Think of a man with fracture of 
the lower end of the radius, which usually needs no splint and 
often need not keep him from his business for one hour, being 
confined to bed with five weights pulling on his unhappy arm! 
These considerations make me believe that a discussion by 
tliis representative body of the treatment of some of the com- 
mon fractures of the upper limb will not be valueless. Sim- 
plicity in dressings, comfort to the patient and very early 
restoration of function are the demands made by the public 
when fractures require treatment. I believe these demands 
* " Leitfaden der Beliandlung von Fracturen mid Luxationen," p. 96 



FRACTURES OF HUMERUS AND RADIUS. 95 

can and will be met in nearly all fractures, if surgeons will 
but use their intelligence, instead of blindly following the 
advocates of special splints; and if systematic authors will 
resist the temptation of describing and cataloguing every de- 
vice that has been employed for these lesions. 

Believing that the methods which I have been led to adopt 
are founded upon good anatomical and pathological reasoning, 
I cannot but think that a trial of the simple dressings proposed 
in this paper will lead to a recognition of their value. I ven- 
ture to hope that their adoption by surgeons generally will 
change the opinion, apparently existing in many minds, that 
good results after fractures at the elbow and wrist are rather 
the exception. I adhere strongly to the statement which I 
made at last year's meeting — that I approach ordinary frac- 
tures at the lower end of the humerus and of the base of the 
radius with a feeling that I shall almost certainly obtain re- 
sults satisfactory to myself as well as to the patient. 

It is proper to explain what is meant here by the term 
" uncomplicated " fractures, since a proper understanding of 
the word as used in this communication is essential to the 
subsequent discussion. I mean fractures in which there is 
no dislocation of the joint, no rupture of large vessels, no 
laceration of the nerve trunks and no unusual contusion or 
laceration of surrounding tissues. In many of the cases 
which I am considering there is involvement of the adjacent 
joint by lines of fracture, splitting the lower fragment. I 
consider these cases uncomplicated, if the fractures are closed 
ones and if the comminution of the lower fragments is not 
extraordinarily great. I am aware that this involvement of 
the joint by fissures is technically a complication; but it is so 
common in the fractures which I desire to bring before you, 
and so unimportant so long as the injury is free from septic 
contamination, that I have used the word uncomplicated in 
connection with it. 

In order to facilitate discussion I shall at once state my 



96 THE MODERN TREATMENT OF FRACTURES. 

opinions and the methods cf practice Avhich I have come to 
adopt in these injuries. They are as follows: 



1. In the treatment of fractures of the lower end of the 
humerus the divergent angle between the axes of the arm and 
forearm must be preserved; and hence dressings which inter- 
fere with the normal difference in level of the radius and ulna 
are not permissible. 

2. Fractures of the lower end of the humerus of ordinary 
severity are, as a rule, more successfully treated in the ex- 
tended than in the flexed position; because the carrying func- 
tion is less liable to be impaired. 

3. Passive motion at an early date is unnecessary, and may 
be deferred until union has occurred and the dressings have 
been finally removed. 

4. Good results as to anatomical conformation and as to 
motion are generally to be expected and can usually be ob- 
tained. 

5. Recent fractures in which satisfactory coaptation is not 
obtained under anesthesia may with propriety be subjected to 
exploratory aseptic incisions. Old fractures in which de- 
formity and impairment of function are marked may, within 
certain limitations, be subjected to refracture or osteotomy for 
the relief of these conditions. 



1. Fractures of the lower end of the radius vary compara- 
tively little in their general characteristics, because but one 
form is usual. 

2. Muscular action has little or nothing to do with produc- 
ing or maintaining the deformity. 

3. Immediate reduction of the fragments is the essential 
of treatment. 



FRACTURES OF HUMERUS AND RADIUS. Vi 

4. Many of the splints devised for the treatment of this 
fracture have been constructed in ignorance of the pathology 
of the condition. 

5. The ordinary fracture of the lower end of the radius 
usually requires no splint, and should be dressed with a wrist- 
let of adhesive plaster or bandage. 

6. When a splint is required a narrow short dorsal splint 
fixing the wrist is all that is necessary. 

7. The method of dressing here advocated is the best, be- 
cause it, by avoiding cumbersome appliances, annoys the 
patient as little as possible, and it permits free voluntary move- 
ments of all of the finger joints. 

8. Passive motion is unnecessary until union has occurred 
and the dressings have been finally removed. 

9. Good use of the wrist and fingers is early obtainable and 
the antomical conformation is restored as well as, and perhaps 
better than, by other more complicated dressings. 

10. Fractures which have been improperly treated by omis- 
sion of immediate reduction, may, Avith considerable success, 
be subjected to refracture even after the lapse of several 
months. At later periods readjustment may be possible only 
by osteotomy, which is a legitimate means of treatment. 

FRACTURES OF THE HUMERUS. 

Surgeons now generally recognize the necessity of maintain- 
ing the so-called carrying function of the upper extremity, 
and methods of treatment which tend to alter the relations of 
the axes of the arm and forearm should be discarded. The 
reasons assigned by Allis * for the frequent occurrence of 
" gunstock " deformity after fracture of the lower end of the 
humerus are, I think, correct. The commonly employed 
splints, and the displacing influence of the ordinary sling, tend 
to bring the ulna and radius on the same level, and thereby 

* " Annals of Anatomical and Surgical Society," Brooklyn, August, 1880. 



98 



THE MODERN TREATMENT OF FRACTURES. 



destroy the divergent angle of the bones at the elbow or create 
an angle in the opposite direction. It is asserted that the 
ascent of the internal condyle one-quarter of an inch will de- 




Normal angle of bones of forearm. (Allis.) 

stroy the normal angular deflection at the elbow.* The direc- 
tion of line of fracture and the point at which it enters the 
joint have, it must be remembered, a great influence on the 




Fig. 17. 
Differing planes of the radius and ulna. (Allis.) 

possible occurrence of change in the axes of the arm and fore- 
arm. The principle is the same as that utilized in condyloid 
and supracondyloid osteotomy in knock-knee. 

*Stimson, "Fractures and Dislocations," p. 403. 



FRACTURES OF HUMERUS AND RADIUS. 99 

Packard makes the important assertion * that the place of 
the articular surface of the humerus corresponds with the 
oblique furrow of the skin on the anterior part of the joint. 
We know, moreover, that when the elbow is flexed at a right 
angle the axes of the arm and forearm coincide. For this rea- 
son, it is much more difficult to be sure that the fragments are 
in the proper position to insure integrity of the angular de- 
flection, when the arm is about to be dressed in the flexed 



Fig. 18. 

Kelatioa of articulating portions of radius and ulna to humerus, in fracture 
of internal condyle ; showing ease with which ulna and broken con- 
dyle can be forced up by splints and bandage, or sling, thus destroy- 
ing carrying function of the arm. (Allis). 

position, than when the surgeon compares the two arms and 
replaces the fragments while the injured limb is extended. 

In my experience the angle of deviation is greater in mus- 
cular persons than in those of opposite development. In 
women and children it sometimes scarcely exists. It is well 
to remember that Pilcher says f that there is a variation in the 
degree of this angular deviation in normal arms of the same 
individual. He found as much as five and one-half degrees 
difference in the two arms of one of the children whom he 

* " International Encyclopaedia Surgery," vol. iv., p. 144. 
+ " Annals of Anatomical and Surgical Society," Brooklyn, September, 
1880, p. 367. 



100 THE MODERN TREATMENT OF FRACTURES. 

measured. In Iris opinion muscular action, particularly the 
action of the triceps, has much to do with the creation of the 
angular distortion which often occurs when elhow fractures 
are treated in the flexed position. 

I see no objection to the surgeon cutting down upon the 
displaced fragments when it is impossible to properly coapt the 
irregular surfaces. An aseptic exploration of a closed fracture 
is better surgery than the conservatism which gives a rigid and 
distorted elbow. 

A surgeon who fully realizes the probability of impairment 
of the carrying function in these fractures can without doubt 
treat them equally well in either the flexed or the extended 
position. Accurate adjustment of the fragments and provi- 
sion for a careful maintenance of the coaptation will usually 
produce good results. In the flexed position plastic dressings, 
made with gypsum and similar agents, are far preferable to 
angular splints of wood, metal or other rigid material. The 
former are made to accurately conform to the limb immedi- 
ately after the surgeon has reduced the fracture ; hence there 
is not much opportunity for subsequent displacement to pro- 
duce a change in the normal outline. If rigid splints are ap- 
plied, however, the movable fragments are liable to be forced 
into undesirable relations by the bandage and sling. This oc- 
currence is possible for many days after the fractured portions 
of the humerus have been skillfully adjusted by the surgeon. 

Practitioners who see comparatively few cases are, how- 
ever, less liable than surgeons to appreciate the probability of 
a " gunstock " deformity. In the flexed position of the elbow, 
moreover, the deviation of the axes of the arm and forearm 
does not exist : hence in this position a slight displacement of 
the plane of the articular surface of the humerus is easily 
overlooked. For these reasons the extended position is the 
better for general adoption, since the angularity of the un- 
broken arm is then noticeable, and any interference with the 
normal deviation is very apparent. 



FRACTURES OF HUMERUS AND RADIUS. 101 

If the sentiment of the profession Avas in favor of usually 
treating these fractures in the extended position there would 
be very many less deformed arms. A specialist will vary his 
methods to suit each case; but for general use is needed a 
rule that will lead the practitioner of average experience and 
intelligence to get good results in the greatest possible number 
of cases. The extended position will, I believe, secure this 
result. By " extended position " I mean that position in 
which the elbow is extended almost, but not quite, fully. The 
forearm and hand are to be supine. Complete extension 
would be exceedingly uncomfortable to the patient, and is not 
what is meant. 

Dr. Lane gave in his paper in the " Transactions " of last 
year a very interesting account of the views of various surgi- 
cal authorities on this question. 

I have for a number of years used a narrow, light wooden 
splint, long enough to extend from the upper part of the arm 
to the wrist, having a divergent angle at the elbow. I usually 
make this splint out of a thin board at the time of dressing 
the fracture, using the sound arm as a guide. A little pad- 
ding of cotton or oakum is laid in the bend of the elbow, to fill 
the hollow present there, because the joint is not fully ex- 
tended. This padding is not intended to make pressure on 
the fragments. In eases where there is too much swelling to 
permit extension of the arm I apply an anterior obtuse angle 
splint or a posterior obtuse angle trough for a few days; but 
I soon change it for the anterior deviating splint above de- 
scribed. This method of treating fractures above the elbow 
has been fully discussed by me elsewhere.* 

In supracondyloid fractures, however, I have employed 
the flexed position, maintaining it by an anterior right- 
angle splint or a posterior right-angle trough. The reading 
and investigation necessitated by the preparation of this paper 
have, however, caused me to incline towards the adoption of 

*" Modern Surgery," Lea Bros. & Co., Philadelphia, 1890. P. 399. 



102 THE MODERN TREATMENT OF FRACTURES. 

the extended position for supracondyloid as well as condyloid 
fractures. The relaxation of the triceps so induced seems to 
me to be desirable, especially as the supination of the forearm 
and hand relaxes the biceps, one of the main opponents of the 
triceps. This position, therefore, relaxes two of the strong 
factors tending to produce the backward displacement, which 
is so much feared by many in supracondyloid fractures or 
epiphyseal descriptions. 

Allis,* Pilcher,f Verneuil,t Gibney, Powers,§ and others 
are correct when they deprecate zeal in the use of passive 
motion in fractures about the elbow and other joints. Stim- 
son puts it very ably when he says,|| " that the anchylophobia 
of the surgeon is more dangerous to the patient than the 
traumatism." Orthopedic surgeons give the same evidence in 
the study of the collateral topic of rest in joint diseases. 
Phelps H has seen normal joints immobilized for ten, twelve 
and eighteen months without anchylosis occurring in either 
the normal or the inflamed articulations. Experimental study 
on dogs has shown the same fact. 

In 1885 I stated in an article on " False Doctrine in the 
Treatment of Fractures " ** that passive motion need not be 
commenced until union of a fracture is pretty well accom- 
plished. My belief is that it may be best for some prac- 
titioners to delay it until union has occurred and the retain- 
ing dressings have been finally removed. If begun earlier it 
may be harmful by giving pain, causing arthritis, or displac- 
ing the fragments. Massage and very slight movements of 
the joint, in judicious hands, will hasten restoration of muscu- 
lar movements and do great good, if begun at the time of 

* " Annals of Anatomical and Surgical Society," Brooklyn, August, 1880, 
p. 306. 
t Idem, September, 1880, p. 369. 
X Quoted by Pilcher. 

§ Medical Record, New York, December 22, 1888. 
I " Transactions American Surgical Association," 1891, p. 269. 
1 " Proceedings Philadelphia County Medical Society," 1891, p. 439. 
** Journal American Medical Association, May 30, 1885, p. 589. 



FRACTURES OF HUMERUS AND RADIUS. 103 

fracture and continued daily. This is not what is usually 
meant by " passive motion " after fractures, and requires skill 
for its proper use. If the doctor does not feel sure of his 
ability in this direction, it is better not to move the joint un- 
til the union is nearly or quite firm. 

It is interesting to note that Dr. L. C. Lane * believes that 
the flexed position of the elbow during treatment of fractures 
of the region under consideration is more favorable to 
anchylosis than the extended; because there is more room for 
neoplastic deposits in the anterior muscular and fibrous struc- 
tures, which are plicated during flexion. 

Deformity and impaired mobility may at times be improved 
by refracture or osteotomy done with careful asepsis. Cases 
for such radical measures must be judiciously chosen. 

Correspondence Avith the Fellows of the American Surgical 
Association, the Members of the New York Surgical Society, 
and the Fellows of the Philadelphia Academy of Surgery, 
shows me that I am correct in the opinion that such uncom- 
plicated fractures of the lower end of the humerus as I am 
discussing usually recover, if judiciously treated, with little 
or no deformity and with good motion. My experience, then, 
is simply corroborative of that of other surgeons. 

Letters sent to these surgeons elicited eighty-eight replies: 

I. 

a. The number Avho preferred the flexed position in 

treatment were, . . . . . . .65 

b. The number who preferred the extended position 

in treatment were, . . . . . .15 

c. The number who employed both positions in treat- 

ment were, ........ 7 

d. The number who gave no definite answer to the 

query was, ........ 1 

Toial, . • 83 

*" Transactions American Surgical Association," 1891, p. 413. 



104 THE MODERN TREATMENT OF FRACTURES. 
II. 

a. The number who preferred the flexed position because 

it was thought to insure better coaptation were, . 37 

b. The number who preferred tbe flexed position because 

there was a fear of anchylosis were, . . .18 

c. The number who preferred the flexed position because 

it was more convenient and comfortable for the pa- 
tient were, ........ 6 

d. The number who gave no definite reason or answer, . 4 

Total, 05 

III. 

a. The number who began passive motion within four 

weeks were, . ....... 64 

b. The number who began passive motion after four weeks 

were, ......... 7 

c. The number who did not use passive motion at all 

were, ......... 15 

d. The number who gave no definite answer to the query 

were, ......... 2 

Total, 88 

IV. 

a. The number who usually expect to obtain good use of 

the joint were, . . . . . . -80 

b. The number who are doubtful about obtaining use of 

the joint were, ....... 8 

Total, . 88 

In studying these tables it must be remembered that the 
manner in which some of the correspondents replied made it 
a little difficult for me to determine under which heading they 



FRACTURES OF HUMERUS AND RADIUS. 105 

should be classed. I have endeavored to classify the replies 
correctly by studying the apparent feeling of the writer as 
well as his phraseology. In some cases several reasons were 
given for the choice of the flexed position; in these I tabu- 
lated the one to which most importance seemed to be attached. 

FRACTURES OF THE RADIUS. 

It is unfortunate that the name of Colles is still associated 
with fractures of the base of the radius. Such personal no- 
menclature is always objectionable; and is especially so here, 
since Colles placed the seat of lesion at a higher point than 
that at which fractures of the base of the radius usually 
occur. 

Fractures of the lower end of the radius vary very little in 
their essential clinical details. The degree of displacement, 
comminution, or impaction is not always the same; but 
through all the variations, due to the character and continu- 
ance of the vulnerating force, the surgeon sees the same es- 
sential lesion, situated at nearly the same point of the bone. 
The treatment, too, needs little variation, and consists in im- 
mediate forcible reduction. 

The usual line of fracture is situated at from one-third 
to three-quarters of an inch above the articular surface of the 
bone, and is generally more or less transverse in direction, 
though some tendency to lateral or antero-posterior obliquity 
is not infrequent. Displacement of the lower fragment back- 
ward upon the lower end of the upper fragment is the ordinary 
deformity, and is due to the fracturing force, not to muscular 
contraction. Some impaction is not unusual from driving of 
the dorsal wall of the upper into the cancellated structure of 
the lower fragment, and actual loss of substance from crush- 
ing of the bony tissue is not infrequent. When impaction 
does not exist, entanglement of the fragments by interlocking 
of the irregular surfaces is very common. At times there is 
no displacement; at others it occurs only at the radial, and 



106 THE MODERN TREATMENT OF FRACTURES. 

not at the ulnar side of the lower fragment, which then is 
tilted obliquely backward. The styloid process of the radius 
is carried upward and backward by this displacement, and 
therefore the radial styloid process is often as high as, or even 
higher (that is, further from the hand) than, the ulnar styloid 
process. This angular displacement tends to throw the articu- 
lar surface with the attached carpus upward, backward, and to 
the radial side, and produces the peculiar deformity so recog- 
nizable. Sometimes the integument over the ulnar head is 
torn asunder by this radial displacement of the hand, and the 
ulna may even protrude through the laceration. Such a 
wound by no means implies an open or compound fracture of 
the radius, for frequently the wound has no communication 
with the fractured surfaces. 

The fracture just described, with or without comminution 
of the inferior fragment, is the one usually seen. Associated 
fracture of the lower end of the ulna, of the ulnar styloid 
process, or synchronous rupture of the radio-ulnar liga- 
ments; and epiphyseal fracture may, however, occur. Frac- 
ture of the lower end of the radius with forward displacement 
is rather rare. 

Fractures identical in pathology and deformity with those 
found clinically can readily be produced in the surgical labo- 
ratory by sudden hyperextension of the hand caused by blows. 
As there is no opportunity for living muscles to assist in 
the production or maintenance of deformity here it is reason- 
able to suppose that muscular action has little influence upon 
the fracture in patients. The tonic contraction of the mus- 
cles of the forearm may be an agent in holding the fragments 
in their abnormal position, when there is simple entanglement 
of the rough surfaces without true impaction, and the ten- 
dons may similarly cause the normal relations to be main- 
tained after reduction by the surgeon. Further than this, 
muscular influences are unimportant, if my experience has 
taught me correctly. The conditions in a transverse fracture 



FRACTURES OF HUMERUS AND RADIUS. 107 

of the base of the radius are very different from those in an 
oblique fracture of the shaft of this or other long bone sur- 
rounded by muscular bellies. The statement * that there is 
a great tendency to displacement by muscular action after re- 
duction has been accomplished is unconfirmed by clinical ob- 
servation, unless there be unusual comminution of the lower 
fragment. When the radius is broken at two and a half 
inches above the joint, or in the middle third of the shaft, the 



Fig. 19. 

Deformity in the usual fracture of lower end of radius. Taken from cast 
made before reduction and treatment. 

conditions are probably different; but I am not considering 
such fractures at this time. 

It seems impossible that any surgeon would think of advo- 
cating the omission of an immediate or complete reduction of 
the lower fragment in this fracture in which non-union is 
practically unknown. Yet, as I have stated in the earlier para- 
graphs of this communication, M. Despres does so. Equally 
astonishing to me is the advice of Dr. Wyeth f that " in 
aged patients, who have considerable impaction, it is not ad- 
visable to break up the impaction." Mr. Southam $ speaks of 
cases in which the deformity cannot be made to disappear, and 
another writer § says that the impaction should be undone if 
possible, implying that impossibility of reduction is not very 
unusual. About ten years ago I treated a woman of perhaps 

♦Holmes' "System of Surgery," Am. ed. by Packard, 1881, vol. i., 
p. 864. 

t " Text-Book on Surgery," 1888, p. 296. 

X Treves' " Manual of Surgery," vol. ii., p. 54. 

§ Druitt's "Modern Surgery," edited by Stanley Boyd. Twelth Am. 
ed., p. 256. 



10S THE MODERN TREATMENT OF FRACTURES. 

seventy years of age who had fallen from a roof to the ground, 
breaking both radii with great displacement. My duty would 
not have been done, in my opinion, if I had not used the same 
force in overcoming the interlocking of the fragments in this 
old woman as I would have employed in a young person. She 
rapidly recovered, with perfect use of wrists and fingers, 
though distortion at the wrist was marked, because of the 
probable comminution of the lower fragment and the fact that 




Deformity produced by aa experimental fracture of the lower end of the 
radius in a cadaver preserved by zinc chloride. A heavy blow was 
struck on pilm, while hand was fully extended, and forearm verti- 
cally placed with elbow on table. 

the woman was imbecile and consequently pulled off the 
splints and dressing. 

That reduction is at times impossible may perhaps be true, 
but I have never seen an instance which the power of my two 
hands, aided by leverage across my knees, could not reduce 
under anaesthesia. Eeduction is to be accomplished by force, 
not by gentle pressure and manipulation, as some would have 
us believe. I usually accomplish it by extension and counter- 
extension applied to hand and forearm, aided by sudden flex- 
ion of the wrist with simultaneous pressure on the dorsum of 
the lower fragment. This maneuver is repeated, if necessary, 
until I feel no ledge of bone at the seat of fracture, when I 
carry my forefinger or thumb along the dorsal surface of the 
lower third of the radius. The reduction is so quickly done 
that anaesthesia is generally omitted. In recent eases this 
manipulation is generally sufficient, but in unreduced cases of 
several weeks' duration, and sometimes in recent cases. I have 
been obliged to bend the limb over my knee so as to break up 



FRACTURES OF HUMERUS AND RADIUS. 109 

the connection between the misplaced fragments. Very firm 
impaction, entanglement of the fragments in the tendons, or 
dorsal periosteal bands may require the surgeon to bend the 
hand and attached lower fragment strongly backward, in 
order to release the interlocking, before making traction, flex- 
ion and pressure. This manipulation is, however, seldom 
necessary. 

It has been asserted that the long supinator or square pro- 
nator opposes reduction of the deformity ; this is undoubtedly 
a fallacy in so far as real obstacle is offered by these muscles. 
Mr. Howard Marsh* makes this extraordinary statement: 
" Should reduction not be accomplished on the first trial, the 
attempt should be repeated a week later, when the fragments 
may have become somewhat loosened on each other, and when, 
swelling having subsided, manipulation can be more accu- 
rately directed." 

Dr. John Ashhurst in a publication issued several years 
ago f makes statements equally misleading and, in my opin- 
ion, exceedingly dangerous. The deservedly high reputation 
of Professor Ashhurst will cause many practitioners to follow 
his words implicitly. The result will, I fear, be the production 
of many unnecessarily stiff wrists and fingers after fracture 
of the base of the radius. He says, " The important part of 
the treatment is, of course, to keep the fragments in their 
proper position. If you bear in mind the mode in which the 
fracture occurs, you can at once see how the compresses which 
we use should be applied to counteract the deformity.*' Two 
compresses, a dorsal and a palmar, and a Bond's splint, are 
used by Dr. Ashhurst, who continues, " "When the compresses 
are brought together, the bones are necessarily pushed into 
position. Even if yoit cannot accomplish this at once, you 
will find that, by careful dressing, in a few days the deformity 
will disappear." 

* Heath's " Dictionary of Practical Surgery," vol. ii., p. 293. 
t "International Clinics," vol. i., p. 201, Philadelphia, 1892. 



110 THE MODERN TREATMENT OF FRACTURES. 

It is possible that this method of dealing with a fracture of 
the lower end of the radius might be admissible and do well 
at the hands of this eminent surgeon in the case he was dis- 
cussing, in which the lower fragment may have been greatly 
comminuted. I feel very sure, however, that the omission to 
call attention to the necessity of immediate and complete re- 
duction, as the first step in all these fractures, is a grave error, 
and that the apparent or intentional direction to rely upon the 
compresses to overcome the deformity is most unwise. 

Further on in his clinical lecture, which was delivered at 
the University Hospital, Dr. Ashhurst states, " I have seen 
sloughing occur from the pressure of the compresses when 
this precaution has not been adopted." The precaution to 
which he has reference is the use of " lead water and lauda- 
num or some other soothing fomentation," in the early stages 
of the treatment, or when there has been much bruising. Is 
it not possible that the sloughing was the result of injurious 
pressure by the compresses rather than the omission of local 
fomentation? The use of the latter, as I have previously 
said, in speaking of fractures of the elbow, is always unde- 
sirable and useless. 

In a paper * read before the Philadelphia Academy of Sur- 
gery nine or ten years ago I mentioned that I had re- 
peatedly been obliged to refracture and reduce fractures of 
the lower end of the radius after treatment in splints by other 
physicians. In a series of forty-eight cases reported at that 
time six cases came to me with the lower fragment still unre- 
duced, though a splint had been applied in each instance. 
This personal experience can be duplicated, doubtless, by 
nearly every surgeon who sees many fractures in hospital or 
consultation practice; and is due to the fact that teachers and 
text-books do not sufficiently emphasize the necessity for re- 
duction. The profession should be shown that the treatment 
of fractures of the lower end of the radius is reduction, and 
not a splint, either with or without compresses. 

* Medical News, December 13, 1890, p. 615. 



FRACTURES OF HUMERUS AND RADIUS. Ill 

The ignorance of the true pathology of this fracture was 
formerly so great that many ridiculous splints have been de- 
vised for its treatment. Many were constructed on the theory 
that the extensor muscles of the thumb were a cause of the de- 
formity; and not a few were employed that failed to recog- 
nize the curvature of the palmar surface of the lower portion 
of the radius. These errors are intelligible and were excu- 
sable; but I fail to appreciate the acumen of the authors who 
still figure these useless antiquities in their text-books or of 
the surgeons who advocate and use them. 

After reduction, the ordinary fracture of the inferior ex- 
tremity of the radius rarely requires such rigid support as the 




Fig. 21. 

Fracture of the lower end of the radius dressed with a wristlet of 
adhesive plaster. 

splint, because the transverse character of the fracture gives 
a broad, rough surface of contact, and the extensor tendons 
running over the dorsal surface of the bone act as tense straps 
to hold down the lower fragment. 

If there is much comminution or if the patient is a careless 
man or a romping boy, it may be wise to use a short and narrow 
dorsal splint upon the back of the wrist. It may be made of 
a piece of cigar box, a strip of metal, or consist of two or 
three whalebones, such as are used in ladies' dress waists. It 
should only extend from the middle of the metacarpal bones 
to the junction of the middle and lower thirds of the forearm, 
being, therefore, about six inches long. Its width need not 
be over one inch. It can be held in place by adhesive plaster 



112 THE MODERN TREATMENT OF FRACTURES. 

or a bandage encircling the limb. This dressing should not 
be employed longer than ten days or two weeks at the most, 
during all of which time the patient should use his fingers as 
freely as pain and swelling will permit. 

In the great majority of cases this dressing is unnecessary. 
and a simple roller bandage, or a wristlet made of two or three 
superimposed strips of rubber adhesive plaster, is all that is 
required. It makes no difference whether the hand is main- 
tained in the prone or supine position during treatment. The 
patient holds it first in one and then in the other, varying the 
position at pleasure. This simple method of treating the frac- 
ture gives the patient the necessary freedom in moving his 
fingers, from the instant the fracture is set, does not prevent 
his wearing a sleeve, allows inspection of the parts, and is in- 
conspicuous, light, clean and efficient. If the surgeon is un- 
willing to use either of these forms of dressing, the molded 
metal splint devised by Levis for application to the palmar 
aspect of the forearm and hand is the best of the special 
splints. The arched or curved nature of the palmar surface 
of the lower third of the radius prohibits a straight splint be- 
ing applied there: but on the dorsal surface a straight splint 
may be used. 

Passive motion need not be employed in fractures of the 
lower end of the radius, for the reasons that I have given in 
speaking of humeral fractures. It is not needed for the wrist 
joint; and the finger joints are being moved constantly by 
the patient during the entire treatment, except when pain or 
swelling makes this impracticable. 

"When, in ten days or two weeks, sufficient union has oc- 
curred for the dressings to be removed, soaking in warm 
water, friction with liniments, and passive motion are useful 
to hasten the restoration of function. This is usually very 
little impaired except in rheumatic subjects, and in cases where 
great associated injury to the soft parts has occurred. 

The dressings employed may usually be discarded in ten 



FRACTURES OF HUMERUS AND RADIUS. 113 

days or two weeks in ordinary cases, and in three or four 
weeks in comminuted fractures. Long retention of the ap- 
pliances is unnecessary, and even deleterious when splints are 
employed, because of the greater tendency to stiffness induced. 

In properly treated cases of ordinary severity, perfect use 
of wrists and fingers is obtained within a few weeks after in- 
jury. Patients can often write a little and use the hand for 
dressing themselves within ten days or two weeks. This fa- 
cility varies with the amount of comminution and inflam- 
mation. Persons of rheumatic or gouty tendencies are proba- 
bly more liable to stiffness of the fingers and wrist than others. 
Fractures in other regions present the same complications in 
such individuals. Much of the rigidity of the wrist and fin- 
gers attributed to rheumatic and gouty causes, or to the se- 
nility of the patient, I believe to be due to imperfect reduction 
of the fragments and to unscientific and unwise treatment. 
I have not recognized the stiffness and rigidity after this frac- 
ture in the aged, which some authors mention with empha- 
sis. I expect the same early and perfect freedom of motion 
in them as in the young, except in so far as the aged are more 
liable to rheumatism and gout. 

It is the opinion of Bryant * that " after this form of frac- 
ture the wrist-joint rarely recovers its normal movement." 
My belief is that after this fracture the wrist-joint usually, 
if not always, perfectly recovers normal movement, provided 
that reduction has been complete at the outset of the treat- 
ment and the case well managed. Moderate deformity, due 
to shortening of the radius, alteration in the plane of its articu- 
lar surface and abnormal prominence of the head of the ulna, 
is not unusual, but is unimportant if motion is perfect, as it 
generally is. 

Mears t advocates early passive motion, and recommends 
that after the removal of the splints, at the end of five or six 

* "Practice of Surgery," fourth American edition, 1885, p. 880. 
f " Practical Surgery," 1885, \\ 206. 



114 THE MODERN TREATMENT OF FRACTURES. 

weeks, the manipulation should be continued to restore func- 
tion and "' remove the rigidity of the articulation which in- 
evitably follows fracture at this point, and enable the patient 
to regain, to a great degree, if not completely, the function of 
flexion, extension, supination, and pronation." This seems to 
indicate his belief that final restoration of motion is possible 
after a long interval. My experience teaches me that it is 
usual almost as early as the date at which Dr. Mears discards 
the splint. 

The statement of Stimson * in discussing this topic is, 
" This rigidity of the fingers is due in part to their prolonged 
immobilization and in part to inflammation within the 
sheaths of their tendons in the forearm.'* This is probably 
correct and indicates the harmfulness of many methods of 
treatment in which the fingers are confined for from four to 
six weeks. Under prognosis, Hamilton f gives the essence 
of the matter in these words, " In cases treated by myself, 
where I have exercised great care in reducing the fragments 
thoroughly, and where the bandages and splints have not been 
applied too tightly, or kept on too long, deformity to any con- 
siderable extent is the exception, and the stiffness is soon dis- 
sipated.'' 

If great comminution or crushing has been incidental to the 
fracture, perfect restoration of the anatomical contour of the 
wrist may be impossible. Eecurrence of deformity may take 
place after reduction has been well accomplished, if there 
be unusual comminution of bone and laceration of ligaments. 
Such cases show preternatural mobility and marked crepitus 
as symptoms. These cases, and even those of less severity. 
quite often present, after union and recovery of normal mo- 
tion, an undue prominence of the ulnar head and a deflection 
of the hand to the radial side. This deformity is due to 

* " Fractures and Dislocations," p. 460. 

f '• Fractures and Dislocations," edition of 1S91. edited by Dr. Stephen 
Smith, p. 284 



FRACTURES OF HUMERUS AND RADIUS. 115 

shortening of the radius, the result of imperfect coaptation of 
fragments, absorption of small particles of the bone separated 
by crushing, change in the plane of the articular surface of 
the radius or interference in young patients with the normal 
growth at the epiphyseal cartilage. This alteration in the 
anatomical conditions of the lower end of the radius may make 
it possible for the patient to voluntarily incline or abduct the 
hand to the radial side very much more than normal. 

In March, 1882, I presented to the Philadelphia County 
Medical Society * several cases of fracture of the lower end of 
the radius. One was a man of sixty years who, after mount- 
ing a high bicycle, had fallen with the machine down a high 
bank. He fractured the left radius and two ribs. The cure 
was so perfect that many members of the Society could not 
tell which had been the broken arm. He was by no means 
young, but never had any stiffness, such as is attributed by 
some writers to age. He has, however, to this day much 
unnatural latitude of motion when he deflects the hand to the 
radial side as the plaster casts of his forearms and hands show. 

When the fragments have not been reduced and vicious 
union therefore results, the surgeon should, as in malunion of 
fractures in other regions, resort to refracture. This can be 
done by bending the limb across the operator's knee, while 
the patient is under anaesthesia; aided, perhaps, by a hyper- 
extension of the hand and wrist. I have successfully done 
this as late as eight weeks after injury and have seen it done 
five and a half months subsequent to the original traumatism. 
The correction of deformity will not be as perfect as in cases 
treated properly from the beginning; nor should such good 
results, as to complete and early mobility of fingers and wrist, 
be expected. Dr. Richard H. Harte f has reported cases in 
which he did osteotomy to overcome the vicious union. I am 
inclined to believe that refracture would have been possible 

* " Proceedings 1881-82," p. 159. 
f University Medical Magazine, 1887. 



116 THE MODERN TREATMENT OF FRACTURES. 

in his cases, as they were seen early. Osteotomy is undoubt- 
edly the proper treatment when refracture requires force lia- 
ble to do serious damage to the soft parts. An aseptic or 
antiseptic osteotomy gives no real risks and allows the surgeon 
to see the bone and choose the exact line of his osseous in- 
cision. 

Questions similar to those mentioned in the discussion of 
fractures of the humerus were sent to the Fellows of the 
American Surgical Association, the Members of the New 
York Surgical Society, and the Fellows of the Philadelphia 
Academy of Surgery. 

This correspondence elicited replies from eighty-eight. 



a. The number who frequently treat fractures of the 

lower end of the radius without any form of splint 
were, ........ 9 

b. The number who always use some form of splint 

were, ......... 78 

c. The number who made no definite answer to this par- 

ticular query was, ...... 1 

Total, . . . . . . .88 

II. 

a. The number who use passive motion within four weeks 

were, ......... GS 

b. The number who use passive motion after four weeks 

were, ......... 3 

c. The number who do not use passive motion at all 

were, . . . . . . . • .15 

d. The number who made no answer to this query were, 2 

Total, 88 



FRACTURES OF HUMERUS AND RADIUS. 11 7 

III. 

a. The number who usually expect to obtain good use of 

the wrist and fingers were, . . . .69 

b. The number who usually expect to obtain good use of 

the wrist and fingers except in aged, rheumatic or 
gouty patients, were, . . . . .13 

c. The number doubtful about obtaiuing good results 

were, ........ -4 

d. The number who made no definite ansAver to this 

query were, ....... 2 

Total, 88 

The same conditions attach to the compilation of this table 
as are mentioned after the similar table relative to fracture 
of the humerus. 



XII. 

THE IGNORANCE OF SURGEONS REGARDING FRACTURE 
OF THE LOWER END OF THE RADIUS. 

A Xew Yoek journal published a few months ago an article 
on fracture of the base of the radius, in which the author, a 
Professor of Surgery, stated that skiagraphic investigation 
showed that these fractures of the radius were frequently as- 
sociated with transverse fracture of the head of the ulna. 
The statement would perhaps have gained professional ac- 
ceptance had the author not reproduced the skiagraphs on 
which his opinion was based, and given the ages of his patients. 
These details made it evident that the supposed fracture was 
the skiagraphic picture of the normal unossified epiphyseal 
cartilage between the shaft and lower end of the ulna. 

Some weeks ago I incidentally saw a fracture of the lower 
end of the radius under the care of a well known surgical 
teacher and writer. It was being treated with anodyne 
lotions and a Bond's splint. I stated that in my opinion the 
fracture was the usual injury with backward displacement of 
the lower fragment, that it had not been reduced and that it 
ought to be immediately subjected to sufficiently great force to 
drive the upper fragment down into position, even if anaes- 
thesia was necessitated for the accomplishment of this essen- 
tial step. To my profound astonishment the surgeon in 
charge said that he believed the fragments were partially 
impacted (to which I fully agreed): that the position was 
prettv good; and that he preferred to leave such cases alone, 
since manipulation such as I proposed would probably in- 
crease the mobility at the point of fracture: and that a com- 
press over the elevation due to the displacement might per- 



FRACTURE OF LOWER END OF RADIUS. 119 

haps be judicious. My surprise at these statements can 
scarcely be expressed. That fractures at the base of the 
radius must be reduced, if deformity, protracted convales- 
cence, prolonged rigidity of joints, and pain are to be avoided, 
was, I thought, accepted by every surgeon of the present day. 
That a compress, applied over the deformity due to impacted 
and unreduced fragments, was a futile substitute for the mus- 
cular force to be exerted on first seeing the injury was, I sup- 
posed, recognized by all surgical teachers. 

My arguments, supplemented by a diagram giving my idea 
of the bony conditions present, failed to convince my col- 
league of the danger of inaction; and, as I had no professional 
connection with the case, I retired from the room before the 
splint was reapplied to the unreduced fracture. 

These two instances are sufficient evidence that much, that 
has been learned regarding anatomy, pathology and surgical 
therapeutics during the last ten or fifteen years, needs con- 
stant reiteration in journals, societies and class rooms. 

It has been my experience to be obliged to set many frac- 
tures of the lower end of the radius, which had previously 
been put up in splints without reduction of the displacement. 
This oversight I have found very prevalent among general 
practitioners, and resident physicians in hospitals. I have at- 
tributed the neglect to reduce the fragments by the former 
class to the teaching of twenty years ago, when the pathology 
of the lesion was misunderstood; by the latter to insufficient 
attention to the instructions of their surgical teachers. 

Among resident physicians and general practitioners, I 
never expect to see the fracture completely reduced. Some 
of them, however, do appreciate the supreme importance of 
immediate and complete reduction and accomplish it; and in 
other instances the fracture has been attended with little or 
no displacement and the neglect to reduce the fragments is not 
demonstrable. 

I now have come to feel that perhaps the oversight in re- 



120 THE MODERN TREATMENT <>F FRACTURES. 

cent graduates is due to the fact that their teachers do not 
insist upon reduction being important: and that undergradu- 
ate students do not see this fracture properly treated in the 
clinical amphitheater and classroom. 

These reflections have induced me to present for discussion 
by the Academy of Surgery the present topic : for I know that 
much physical suffering will be avoided and the surgical art 
advanced by having the young graduates, whom the Fellows 
of this body teach, impressed with the idea that failure to re- 
dtice, as soon as possible, a fracture of the base of the radius 
is an injustice to the patient and an opprobrium of surgery. 

In conclusion, I state my position in regard to this fracture 
in sis propositions: and would be glad to have every Fellow do 
likewise for record in the discussion. 

1. Fracture of the lower end of the radius is one of the 
most satisfactory of all fractures to treat, 

2. The patient, as a rule, has little discomfort after the 
first twenty-four hours, except from the disability and the 
annoyance of the sling and dressing. 

-"iffness of the fingers and wrist-joint is seldom present 
to any marked extent after a week. 

4. Deformity is usually so slight as to be unnoticeable to 
the average observer, except in cases where there has been 
marked comminution of the lower fragment. 

•;■. These assertions are only justified when the surgeon 
insists upon forcing the lower fragment into its proper ana- 
tomical relation with the upper fragment. This is to be done 
by the exercise of such a great amount of force as will break 
up all impaction or entanglement and bring the broken sur- 
faces into accurate coaptation. This sometimes, but not usu- 
ally, requires general anaesthesia: and may demand that the 
surgeon bend the broken bone across his knee in order to dis- 
entangle the interlocked fragments. 



XIII. 



DEDUCTIONS FROM FORTY-THREE CASES OF FRACTURE OF 
THE LOWER END OF THE RADIUS, TREATED WITHIN 
THREE MONTHS. 

Fkacture of the lower end of the radius is, in all proba- 
bility, treated improperly more frequently than fracture of 
any other part of the skeleton; yet, if treated in a rational 
manner, it results in a more rapid and better functional cure 
than any other similar injury. 

A large number of otherwise intelligent practitioners, sur- 
geons not excluded, do not understand the mechanism of the 
fracture, nor the exact cause of the peculiar deformity ; hence 
it is not uncommon to see such fractures woefully mismanaged 
and the patient subjected to months of unnecessary disability. 

The usual cause of the injury is forced extension of the 
radio-carpal articulation, which produces a transverse fracture 
of the lower end or base of the radius, about three-eighths 
or half an inch above the articular surface. The line of 
break is not always exactly transverse, but for practical pur- 
poses, it may be considered transverse. 

The characteristic deformity is due to the fracturing force 
driving the lower or basal fragment upward and backward 
upon the shaft or the shaft downward and under the basal 
fragment, so that the basal fragment becomes caught or even 
impacted upon the dorsal edge of the shaft fragment. Muscu- 
lar action has little or nothing to do with the production or 
continuance of the deformity. 

In some cases no deformity exists, because the fracturing 
force was not sufficient to cause displacement; then the diag- 
nosis may rest entirely upon a localized point of great and per- 
121 



122 THE MODERN TREATMENT OF FRACTURES. 

sistent tenderness, about half an inch above the joint, and the 
occurrence of a ridge of callus as a later symptom. 

In sprains of the wrist the point of tenderness and the 
swelling due to consequent synovitis, will be half an inch 
lower than in these fractures without displacement. If the 
lower fragment is comminuted, as occurs in severe fractures, 
the characteristic pain and swelling of svnovitis will probably 
be present in addition to the symptoms of fracture. When 
the fracture shows no deformity, there usually exists no com- 
minution and hence no synovitis, and diagnosis is to be made 
only by the localized and persistent pain and the subsequent 
ridge of callus. 

The reduction of the fracture is the most important element 
in the treatment of the injury, and is often ineffectually ac- 
complished, because of the ignorance or carelessness of the 
attendant. In many cases reduction is not even attempted 
before the dressings are applied. TVhen reduction has once 
been thoroughly accomplished, the displacement is not apt to 
recur, unless the lower fragment be comminuted. 

Traction, sudden flexion of the wrist, and direct pressure 
upon the dorsal aspect of the lower fragment are the proper 
means of effecting reduction. 

Many cases need no splint if the patient is sufficiently in- 
telligent to avoid subjecting the injured bone to sudden 
strains. 

Comminuted fractures, of course, need more support, such 
as is afforded by splints, than do non-comminuted ones; while 
fractures without original displacement probably never need 
the support of a splint. 

It is probable that no transverse fracture of the base of 
the radius ever requires a splint longer than from ten to four- 
teen days. 

Perfect function of the fingers is the rule a very few weeks 
after the accident, provided that reduction has been promptly 
and fully effected immediately after the injury, and the treat- 



FRACTURE OF LOWER END OF RADIUS. 123 

ment such as not to restrain the motion of the fingers during 
the wearing of the splint. 

Slight stiffness of the wrist may be expected to exist for 
some six weeks after the receipt of injury; and some thicken- 
ing about the seat of fracture will persist for two or three 
months. 

Permanent shortening of the radius, producing a slight in- 
clination of the hand to the radial side, is to be expected in all 
cases, but often is detected by very close scrutiny. 

The statement of many authorities, that long-persistent 
disability from stiffness of wrist and fingers may be expected, 
is I am sure, in the majority of cases, absolutely incorrect, 
and is due to observation of cases improperly treated. 

I have made no reference to methods of treatment, because 
such teaching is apt to lead to unintelligent practice, whereby 
a described form of dressing or a delineated splint is applied 
without the attendant having properly appreciated the char- 
acter of the injury or having effected reduction. A fracture 
of the lower end of the radius, once properly reduced, will 
do better without any professional attention whatsoever, than 
will one only partially reduced, dressed with the most perfect 
splint. 

In my own practice I use Levis's metal radius splint, ap- 
plied to the palmar surface, for cases where there is need of a 
good deal of support. In other cases I use a short steel or 
wooden splint about six inches in length and a half -inch wide, 
applied to the dorsum of the wrist by adhesive plaster or a 
bandage. A piece of corset steel is convenient for the pur- 
pose. Cases with no displacement need nothing more than 
a band of adhesive plaster around the wrist. This is a suffi- 
cient splint for many other cases after reduction. 



XIV. 

HEEDLESSNESS OF SPLINTS IN FRACTURE OF THE 
LOWER END OF THE RADIUS. 

The treatment of fracture of the lower end of the radius 
is exceedingly satisfactory, because the character of the 
injury seldom varies and because the results obtained are usu- 
ally good both in rapidity of cure and in perfect restoration of 
the function. 

This statement is, perhaps, unexpected, since it is not un- 
usual to find the opinion expressed in text-books that this frac- 
ture is troublesome to treat and very liable to be followed by 
deformity of the wrist and stiffness of the fingers. I am con- 
vinced that such unfortunate results usually come from mis- 
management of the fracture, and are due to a want of appre- 
ciation of the nature of the lesion and of the necessity for 
forcible reduction immediately after its receipt. These errors 
of judgment and treatment are perpetuated by the current 
belief that the essential treatment of a fracture is the appli- 
cation of a splint. 

I purpose showing that in a great proportion of cases frac- 
ture of the lower end of the radius needs no splint; and hence 
that splints for this injury are usually needless. If the ten- 
dency to use a splint impels the practitioner to neglect the 
all important reduction of the fracture, my position, it seems 
to me, is strengthened. 

The innumerable forms of splint devised for fracture of the 
lower end of the radius show how much this very common in- 
jury has interested the profession. Some of these splints have 
done great harm because the}' have misled the practitioner as 
to the nature of the lesion. A few of them are very good, in 



FRACTURE OF THE RADIUS. 125 

that they have been devised in accordance with the anatomy 
and pathology of the osseous lesion. As, however, in the vast 
majority of cases, none of them is really needed they are prac- 
tically useless. The fact that positive harm is liable to be 
done by their use is a point in advocacy of the abandonment 
of all such appliances. 

The usual cause of the injury is forced extension of the 
radio-carpal joint, which produces a transverse disruption 
through the lower end of the radius from three-eighths to 
one-half an inch above the articular surface. The character- 
istic deformity is caused by the fracturing force driving the 
lower fragment upward and backward upon the shaft, or 
thrusting the shaft downward and under that fragment, so 
that it is caught or impacted upon the dorsal edge of the shaft 
fragment. Occasionally there is a tendency to lateral or 
antero-posterior obliquity of the line of fracture, but this is 
quite unimportant. The displacement sometimes occurs much 
more markedly at the radial than at the ulnar side of the 
lower fragment, which is then tilted obliquely backward, 
carrying the styloid process of the radius upward and back- 
ward, so that it is on a level with, or even higher than, the 
styloid process of the ulna. This angular displacement tends 
to throw the articular surface with the attached carpus up- 
ward and backward to the radial side, causing thereby undue 
prominence of the lower end of the ulna. 

Muscular action has nothing to do with the production or 
the continuance of the deformity. In cases in which the 
fracturing force has not been sufficient to cause displacement, 
no deformity exists, and in such instances the diagnosis rests 
upon a localized point of great tenderness about half an inch 
above the wrist-joint. 

Sometimes comminution of the lower fragment takes place 
so that lines of fracture enter the radio-carpal joint. The 
ligaments and cartilages are sometimes extensively injured, 
and sometimes there occurs actual loss of substance by crush- 



126 THE MODERN TREATMENT OF FRACTURES. 

ing and pulverizing of the bone tissue. These complications, 
except that of comminution, are quite rare. 

Reduction of the fracture, the most important element in 
the treatment of the injury, is often ineffectually accom- 
plished, or, indeed, not attempted. This is owing to ignorance 
rather than carelessness on the part of the attendant. "When 
reduction is once thoroughly accomplished, displacement is 
not apt to recur, because the broad rough surfaces of bone are 
held together by their serrations, and because there are no 
muscular masses tending to displace the fragments. 

The condition, it will be observed, is quite different from 
oblique fracture of the shaft of the bone, in which it is often 
difficult to maintain accurate apposition because of the mus- 
cular displacing forces. Hence if reduction, which is the 
essential in treatment, is properly performed, no splint is 
needed. On the other hand, if reduction is neglected, no 
splint will act as a substitute for it. If reduction has been 
properly accomplished, an improper splint may displace the 
lower fragment and cause recurrence of the deformity. 
Hence, abandonment of splints is often a proper course to 
pursue. 

Comminuted fractures, of course, need more support than 
non-comminuted ones; but even here, the simple support of a 
bandage applied in a circular manner or of strips of adhesive 
plaster wound around the wrist like a collar will usually be 
found sufficient. 

In uncomplicated fractures treatment is required for about 
three weeks. 

Perfect function of the wrist and fingers may be expected 
in nearly all cases; provided that reduction has been properly 
effected immediately after the injury, and provided that the 
fingers have not been restricted in motion at any time during 
the treatment. Slight stiffness of the wrist may be expected 
for a few weeks in complicated cases; and in such injuries 
some thickening about the seat of the fracture will persist 



FRACTURE OF THE RADIUS. 127 

for two or three months. Slight shortening of the radius, 
due to loss of tissue by crushing and absorption, occtirs in 
most cases, but the resulting inclination of the hand to the 
radial side in well-treated cases of average severity can usually 
be detected only by very close scrutiny. 

The statement of some authors that long-continued dis- 
ability of the wrist and fingers is to be expected is, I believe, 
untrue in the average case of fracture of the lower end of the 
radius; and is due to observation of cases improperly treated. 

The danger of many of the splints advocated for this frac- 
ture is due to the non-recognition by their respective inventors 
of the curved or arched shape of the palmar surface of the 
lower third of the radius. The dorsum of the bone when 
covered with the tendons is straight, but the palmar surface 
is curved. It is readily understood, therefore, that the appli- 
cation of any straight splint (such as that called Bond's 
splint) to the palmar surface of the broken radius has a ten- 
dency to displace the lower fragment upward again, as soon 
as the bandage which retains the splint in position is applied. 
A straight splint may, however, be applied with propriety to 
the back of the wrist. I have used with satisfaction two or 
three pieces of whalebone held in position by a strip of ad- 
hesive plaster. Any rigid article, such as a piece of steel or 
wood, half an inch wide and five or six inches long, will an- 
swer the purpose. The truth is, however, that in a person of 
ordinary intelligence, who will avoid subjecting the bone to 
severe strains, there is no need of any rigid splint or support. 
Exceptions to this rule may perhaps be found in the case of 
refractoiy children and of ignorant or stubborn adults. The 
fact that these persons are liable to itse the hand at an early 
period, and in such a way as to cause a slight risk of displace- 
ment of the fragments, is evidence of the simplicity and pain- 
lessness of the injury and of the satisfactory manner in which 
union takes place, if reduction has been properly effected. 

That the treatment of the fracture is misunderstood by 



128 THE MODERN TREATMENT OF FRACTURES. 

many practitioners is evident to me from the fact that I have 
repeatedly been obliged to refracture and reduce partially 
united fractures of this kind after several weeks' treatment 
in splints. In a number of instances an exceedingly good 
splint had been applied though the fracture had not been re- 
duced. A quite recent experience of this kind in which I 
refractured the bone eight weeks after the injury has forcibly 
brought the subject to my mind. 

Osteotomy, for the purpose of correcting such deformities, 
is seldom if ever required. I have known a deformed fracture 
of the radius to be broken for re-adjustment five and a half 
months after the injury. To do this requires considerable 
power, but it can generally be accomplished by forcibly bend- 
ing the bone across the operator's knee. 

A few years ago, while holding a position as out-patient 
surgeon in one of the hospitals of this city, I had occasion to 
treat, within less than three months, forty-two cases of fracture 
of the lower end of the radius. Some of these were treated 
with the molded metal splint recommended by Dr. Levis: 
others were dressed with a straight dorsal splint of wood: 
while in some the wrist was immobilized by means of a single 
strip of steel, or two or three strips of whalebone applied to the 
dorsum of the joint by means of adhesive plaster encircling 
the limb. A few were treated during a part of the time by 
applying to the palmar surface a curved steel strip, such as 
the " busk-bones " of corsets. 

It will be observed that six cases came to me with the 
lower fragment still unreduced, although in each instance a 
splint had been applied. In five of these cases Levis' molded 
splint, the best splint manufactured for this fracture, had 
been applied. This fact proves my assertion that it is the cus- 
tom of many to apply a splint, and often a very proper one. 
without reducing the fracture. It is this belief in the thera- 
peutic value of the splint which causes many physicians to 
have bad results in the treatment of this fracture. If the 



FKACTURE OF THE EADIUS. 129 

profession were made to understand that no splint can be con- 
structed which will take the place of reduction, better results 
would be more frequent. 

. It is interesting to note that all, or nearly all, of the cases 
tabulated had been originally dressed by the resident physi- 
cians belonging to the wards of the hospital. It is also worthy 
of notice that these residents belonged to a hospital with 
which at the time were connected two surgeons who have 
written and done most effective work in teaching the pathol- 
ogy and proper treatment of this particular injury. 

The table is instructive, I think, as showing that perfect 
motion without special deformity was obtained in almost every 
case. It must be remembered, in addition, that these records 
were made a few weeks after the receipt of the injury, and 
that the results, so good at that time, probably became more 
perfect after the lapse of a longer period. 

At the present time I should be inclined in nearly all cases 
to treat the fracture without using any splint at all; or, at 
most, I should employ only a thin strip of steel or zinc, or a 
couple of pieces of whalebone, six inches long, applied to the 
dorsum of the wrist, and held in place by strips of adhesive 
plaster. 

When the tabulated cases were treated the time during 
which restrictive dressings were continued was probably less 
than would be advocated by most surgeons. I have seen no 
reason to alter my practice in this regard, except perhaps to 
shorten the time still more. I am now convinced that a roller 
bandage or a strip of adhesive plaster applied to the wrist in 
a circular manner is all that is necessary, except in unusually 
complicated fractures. All ordinary forms of splints should, 
as a rule, be discarded as useless, needless, or dangerous. 

The proper treatment of fracture of the lower end of the 
radius is reduction. Little else is required in the ordinary 
cases. 



XV. 

THE NECESSITY OF FORCE EN THE TREATMENT OF 
COLLES' FRACTURE OF THE RADIUS. 

Tms paper is presented to call attention to the fact that it 
usually requires a great deal of force to fully reduce the 
ordinary fracture of the lower end of the radius. Much has 
been written on the pathology and treatment of this injury, 
but sufficient stress has not been laid on the need of force — 
great f orce — to fully replace the lower fragment. This frag- 
ment is driven backward by the impact of the hand against 
the ground when the patient falls and sustains the injury. 
The displacement is nearly always accompanied by entangle- 
ment of the two fragments with each other, or by impac- 
tion of the dorsal edge of the upper fragment and the cancel- 
lated tissue of the lower fragment. Very generally the 
physician or surgeon who sees the case (and I include the 
Avord surgeon advisedly) fails to apply sufficient power, while 
setting the fracture, to disentangle the pieces of bone, and the 
backward displacement is not overcome. As a result the so- 
called silver-fork deformity is only partially corrected or not 
corrected at all, and the patient has a prolonged convales- 
cence with neuralgic pain, oedema, and stiffening of the fin- 
gers. If, on the other hand, the amount of power applied is 
great enough, the lower fragment will be detached from the 
upper and driven forward into its place, so as to restore the 
concavity of the palmar surface of the lower end of the 
radius and make the dorsal surface practically level. Then 
there will be little pain or discomfort, and no marked or pro- 
longed oedema or stiffness of the fingers. 

It would, perhaps, be well if fractures of the lower end of 



FRACTURE OF THE RADIUS. 131 

the radius were treated by laving the patient's arm flat on the 
table and, after covering the dorsal surface with a folded 
towel, striking a good blow on the back of the wrist with a 
heavy wooden mallet. This would compel the practitioner 
to employ force enough to drive the lower piece of bone into 
position, which the average man seems afraid to do with his 
hands. 

These statements are made — in fact this paper has been 
prepared — because last month I had under my care at the 
same time two cases in which I was obliged to refracture a 
united but unreduced Colles' fracture of the radius. One 
was a woman who had broken the bone six weeks before, 
and had gone for treatment to the dispensary of one of the 
largest Philadelphia hospitals; the other was a woman who 
had been treated for nearly four weeks in the wards of one 
of the college hospitals of this city. In neither case had the 
fracture been reduced, and the deformity of the wrist and 
stiffness of the fingers were such as would be expected under 
such circumstances. By bending tbe bone across my knee I 
ruptured the bone of union, put the fragments in better po- 
sition, and have had quite satisfactory convalescence. 

I do not want to be understood as saying that I advocate a 
blow from a wooden mallet as the best method of reducing 
these fractures; but I use the illustration to show that it re- 
quires unusual force to accomplish the necessary replacement 
of the fragments. The physician has the needed strength in 
his own hands, but ordinarily he does not use it. Sudden 
flexion of the wrist, with great pressure upon the back of the 
lower fragment, will nearly always crush the piece of bone 
into place. This gives great pain, but anaesthesia may be em- 
ployed if preferred. The setting is done so suddenly that 
usually no ether is necessary. AVhen the prominence on the 
back of the arm, caused by the backward displacement of the 
lower fragment, does not disappear, the effort at reduction 
must be repeated. On rare occasions it may be well to bend 



132 THE MODERN TREATMENT OF FRACTURES. 

the hand and lower fragment strongly backward, to disen- 
tangle the fragments, before making flexion and pressure to 
push the basal fragment forward. 

As soon as all practitioners adopt these forcible manipu- 
lations to set the fracture and abandon the dangerous Bond's 
splint, little will be heard of unsatisfactory results and long 
periods of disability in Colles' fracture. The reduction, 
which is the essential of treatment, is the step usually neg- 
lected. A straight splint on the back of the wrist, a molded 
splint fitting the palmar surface, or a wristlet of adhesive 
plaster applied around the lower end of the radius is the 
proper treatment after reduction. The reduction must be 
accomplished by force, except in the few cases where there is 
no displacement. 



XVI. 



FRACTURE OF THE LOWER END OF THE RADIUS 
WITH FORWARD DISPLACEMENT. 

My object this evening is not so much to discuss the pa- 
thology and treatment of this injury as to show some casts and 
photographs of the lesion, which. I purpose placing in the 
Mutter Museum, and to exhibit to the Fellows three interest- 
ing specimens already belonging to that valuable collection. 

A recent study * of this fracture has convinced me that its 
occurrence is not very rare, and that its recognition is not gen- 




Fig. 22. 
Probable Epiphyseal Fracture. (Mutter Museum.) 

eral. Within a few years I have seen four cases, all of which 
had previously been under professional care. Yet in none of 
them had the deformity been reduced; and in the history of 
three, if not of all four, it was evident that the true character 
of the injury had not been suspected. 

Well known is the widespread ignorance in the profession 

of the necessity for very forcible primary reduction of the 

inferior fragment in the usual fracture of the lower end of the 

radius with backward displacement. It seems as if there 

* " Transactions American Surgical Association," 1896. 



134 THE MODERN TREATMENT OF FRACTURES. 

exists an even greater degree of ignorance or forgetfulness 
of the possibility of the displacement occasionally being for- 
ward instead of backward. If the possibility of snch displace- 
ment is generally recollected, it must be that the necessity 
for forcible primary reduction is not appreciated, for in the 
cases seen by me and in the collection of photographs here 
exhibited the deformity had not been reduced. 

This lesion, sometimes termed " Smith's fracture of the 
radius." at otber times called " Reversed Colles"s fracture " 




Fig. 23. 
Fracture with Probable Stripping up of Periosteum, i Mutter Museum.) 

may be produced, if my experimental and clinical studies are 
correctly interpreted, in three ways: 

1. Tearing off of the lower end by a cross-breaking strain 
exerted through the posterior Ligaments during extreme flex- 
ion, when the force is applied to the back of the hand in front 
of the anterior surface of the radius. 2. Crushing of the 
anterior petition of the bone between the wrist-bones and the 
shaft, or mutual penetration of the diaphyseal and epiphyseal 
portions. 3. Rupture of the bony tissue of the weakest point 
by decomposition of the force to which the limb is subjected. 
It is possible that there may be at times a combination of 
more than one method. 

In a recent case, treated by my colleague. Dr. 31. J. 
Stern, at the Polyclinic Hospital, the character of which was 
proved by an immediate skiagraph taken by Dr. Stem, the 
boy seemed to have received the blow on the palmar surface 



RADIAL FRACTURE DISPLACED FORWARDS. 135 




Fig. 24. 
Skiagraph of Dr. Stern's Case before Reduction. 



136 THE MODERN TREATMENT OF FRACTURES. 

of the ulnar side of the hand. He was getting upon a horse 
and fell over on the opposite side of the animal. When 
examined shortly afterwards the damage done to the skin of 
the hand by impact on the ground was shown on the palm 
of the hypothenar eminence and on the ulnar border of the 
hand. The displacement forwards, of the lower fragment and 
the over-riding of the upper fragment upon its dorsum are 
beautifully shown in the skiagraph, which Dr. Stern has 
brought here to-night. Forcible reduction was at once per- 




Fig. 2.3. 
Oblique Fracture. (Museum, Trinity College, Dublin.) 

formed and the boy now has an excellent arm with little or 
no deformity. 

It can be understood, I think, how such a blow might tend 
to displace the radial base forward rather than backward. A 
fall directly upon the whole palm usually tends to forcibly 
extend the wrist-joint and is one of the methods of producing 
the classic fracture with backward displacement. This blow 
coming on the ulnar portion of the hand might readily, it 
seems to me, drive the lower fragment forward without ex- 
tending the wrist-joint. 

The deformity in this fracture is quite different from that 
in the ordinary injury with backward displacement. The 
degree naturally varies with the amount of displacement and 
the obliquity or transverse character of the line of fracture. 
It may be almost absent or be very great. Sometimes the dis- 



RADIAL FRACTURE DISPLACED FORWARDS. 



137 



placement is almost entirely forward, at other times it is 
comparatively slight forward, but very marked in a radial 
direction. The photographs here shown illustrate these varia- 
tions very well. The Edinburgh and ISTew York specimens 




Fig. 27. 



Two Views of Fracture with great forward displacement. (Museum 
Royal College of Surgeons, Edinburgh.) 

have marked forward displacement; the specimens from the 
Royal College of Surgeons in Ireland marked lateral displace- 
ment towards the radial aspect of the forearm. The deform- 
ity of the forearm and wrist is characteristic in instances where 



138 



THE MODERN TREATMENT OF FRACTURES. 



the carpal fragment is much displaced forward. An elevation 
is seen across the hack of the forearm, running obliquely up- 
ward from the ulnar to the radial side. The ulnar portion of 
this elevation is the more prominent, and is made by the head 
of the ulna, which was left behind when the carpal fragment 
of the radius Avith the attached hand was carried forward by 
the injury. On the radial side of the limb the elevation is 
further from the hand and is less prominent. It is due to the 
lower end of the upper fragment of the radius. 

This dorsal prominence is quite different in appearance 
from the hump on the radial side of the dorsum seen in the 




Fig. 2i 
Two views of specimen in Museum of St. Thomas's Hospital, London. 



fracture of the lower end of the radius with backward displace- 
ment of the carpal piece. In the latter ease the elevation is 
great on the radial half of the limb, and the surgeon's finger 
carried along the back of the shaft of the radius can readily 
feel the ledge of bone corresponding to the dorsal surface of 
the lower fragment. The ulna makes little or no prominence 
on the back of the forearm in the classic fracture, though 
in both forms it is apt to be prominent on the ulnar edge of the 
limb, because the outward displacement, common in both in- 
stances, carries the hand away from the head of the ulna. 
In the fracture under consideration the surface slants down- 



RADIAL FRACTURE DISPLACED FORWARDS. 139 

ward from the dorsal elevation toward the back of the hand, 
whose plane is at a lower level than that of the forearm, but 
more or less parallel to it. 

This slant in the surface below the dorsal elevation causes 
somewhat the appearance of a furrow across the forearm, 
which is deeper just below the head of the ulna. Pressure 
with the fingers will make this hollow more evident, and show 
that the lower end or base of the radius occupies a position 
more anterior than normal. This sulcus is, as the elevation, 
a little further from the hand on the radial side. 

The lowe^* fragment will usually be felt &s a hard mass 
under the flexor tendons, evidently not pertaining to the ulna. 

Lateral deviation towards the radial side of the forearm is 
probably usual. This specimen, from the Mutter Museum, is 
an extreme example of this lateral deformity due to a crushing 
or absorption at an oblique line of fracture. 

This tendency to lateral displacement causes the radial 
styloid to ascend towards the elbow in this fracture as in that 
with backward displacement of the lower fragment. 

The treatment is simple if the fracture be only recognized, 
— immediate and forcible reduction to restore the contour of 
the lower portion of the radius, followed by the application of 
a molded splint of metal or gypsum to the palmar surface or 
a straight splint to the dorsum. There is little or no danger 
of muscular displacement. The displacement is due, as in the 
classic fracture, to the vulnerating violence, not to muscular 
action. It is possible that the eoneave shape of the palmar 
siirface of the lower end of the radius and the great strength 
of the flexor muscles may sometimes lead to displacement 
from muscular action. This is practically never present in 
the common fracture with posterior displacement of the lower 
fragment. The so-called Bond's splint often injudiciously 
employed in the classic fracture is equally undesirable here. 



XVII. 

A CASE OF FRACTURE OF THE LOWER END OF THE 
RADIUS WITH ANTERIOR DISPLACEMENT OF THE CAR- 
PAL FRAGMENT. 

This injury is more frequent than is generally supposed. 
A recent investigation which I made has convinced me of the 
importance of the lesion. It is possible that a skiagraph of 
snch a fracture may interest other surgeons. 

A boy of about twelve years fell from a bicycle, injuring his 
wrist. He gave the injury no special attention, but at the 
end of about four weeks applied to Dr. It. Kindig for treat- 
ment. By Dr. Kindig he was referred to me because of the 
unusual deformity. It was evident from the appearance that 
there had been a fracture of the radius about an inch and a 
half above the wrist-joint and that the lower fragment was 
displaced anteriorly. Union was quite firm as would be ex- 
pected at the end of four weeks. The skiagraph taken before 
treatment shows the line of fracture, the forward displacement 
of the carpal fragment, and the callus deposited for the repair 
of the lesion. 

■ I refractured the bone and put the fragments in proper posi- 
tion. There was a good deal of tendency to reproduction of 
the displacement, and I was obliged to resort to anterior and 
posterior straight splints to keep the fragments in proper posi- 
tion. I believe the tendency to repeated displacement was 
largely due to the fact that the fracture was farther from the 
wrist than is usual in fracture of the lower end of the radius. 
As a consequence, muscular action had more influence in pro- 
ducing displacement than is common when the fracture is 
nearer the joint. At the lower point the broken surfaces are 

140 



RADIAL FRACTURE DISPLACED FORWARDS. 



141 



more extensive because of the greater thickness of the bone, 
and therefore retain their position better when once adjusted. 
My ordinary treatment of fractures of the base of the radius 




Author's Case of Recent Fracture of the Lower End of the Radius 
Forward Displacement. 

by the metal splint of Levis or by a band of adhesive plaster 
around the wrist, was not sufficient to keep the fragments 
properly coapted. The skiagraph was taken with the radial 
side of the ami against the photographic plate. 



XVIII. 

FRACTURE OF THE LOWER EX.D OF THE RADIUS WITH DIS- 
PLACEMENT OF THE LOWER FRAGMENT FORWARDS.* 

This boy of fourteen years presents himself for treatment 
for pain in the left wrist, which followed shoveling snow. 
Inspection of the hand and wrist shows an unusual deformity, 
which consists in deviation of the hand to the radial side and 
the presence of an elevation on the palmar aspect above the 
base of the thumb. The boy says that last August a year, 
which is now eighteen months ago, he fell from a cherry tree 
and broke his left wrist. He was brought to town and taken 
to a hospital in the evening of the same day; there he was 
treated by manipulation of some sort and the application of 
a wooden splint to the palmar surface of the forearm. He 
wore the splint for about five weeks. He now has perfect use 
of the fingers and of the wrist-joint; but has a deformity, 
which makes it evident that there was a fracture of the radii;? 
with displacement of the lower fragment anteriorly, instead of 
backward as in the usual fracture at this point, and that the 
present deformity is the result of union with the fragments 
unreduced. 

Careful examination shows that the hand is displaced to the 
radial side, and thereby causes the head of the ulna to be 
prominent at the ulnar side of the wrist, though it does not 
project backward to any special degree. On the palmar sur- 
face at the lower end of the radius a mass of bone can be dis- 
tinctly felt lying beneath the flexor tendons. The edge of 
this bony mass, which is the cai*pal fragment, is situated about 
an inch above the base of the thenar eminence. The bulge 
* From the " International Clinics," 1897. 



KADIAL FRACTURE DISPLACED FORWARDS. 



143 



produced by tlie lower fragment is more clearly shown when 
the patient makes a fist, because then the flexors of the fingers 
are contracted and the muscular bellies at the wrist are drawn 
up the forearm and leave only tendons lying over the bony 
mass. This makes the outline of the bone more prominent. 
The lower end of the ulna is not involved in this mass of bone. 
The radius when grasped by the fingers antero-posteriorly at 
its lower end is much thicker than that in the normal arm, 
and the lateral width of the forearm just above the joint is 
increased. The radial styloid process is about three-eighths 
of an inch nearer the elbow on the injured side than in the 
right arm. Deep pressure gives an impression to the fingers 




Fracture of lower end of radius with forward and lateral displacement of 
lower fragment ; the lateral displacement very marked. (Cast from 
specimen in Dublin, Ireland.) 

that the fracture was oblique, the line running from the ulnar 
side of the radius upward and outward toward the radial side 
of the bone. When the palm of the hand is laid flat on a 
table, the front of the forearm lies closer to the table than in 
the normal arm. This is due, I think, to the fact that at the 
time of fracture the carpal fragment was rotated, so as to make 
the hand abnormally pronated. There is no special increase 
or diminution in either flexion or extension of the wrist-joint. 
The boy tells us that this deformity has existed without incon- 
venience since the time of the accident. I find, however, that 
he has a little pain in the wrist after using the hand for hard 
work, and it was this which brought him to the hospital for 



144 



THE MODERN TREATMENT OF FRACTURES. 



treatment. Here is a photograph jf a similar fracture in an 
adult. 

This injury is an unusual one and very apt to be overlooked, 
because the attention of surgeons has not been called to the 
condition as particularly as it ought to be. 




Fig. 32. 

Fracture of lower end of radius with moderate forward displacement 
(radial side). 

I showed here a couple of years ago a woman who had 
sustained this same fracture. It had evidently not been recog- 
nized, for the fragments, as in the case of this boy. had not 
been perfectly reduced. Here is a plaster cast (Figs. 32 and 
33) of her hand and forearm, which shows a similar deform- 
ity to that exhibited by the boy. except that the hand is not 




Fig. 33. 

Fracture of the lower end of the radius with moderate forward displace- 
ment (ulnar side). 

deviated much to the radial side. This condition is due to 
the fact that the fracture was not as oblique as in the patient 
now before us. and that the displacement forward was very 
marked. This skiagraph shows the bony changes (Fig 

Very little study has been given to this fracture, and many 
men of large experience have apparently not seen it. Many 



KADIAL FRACTURE DISPLACED FORWARDS. 



145 



of the text-books refer to the possibility of the injury, but give 
no cases and refer to no specimens. At the meeting of the 
American Surgical Association a year ago I called attention 
to this subject, and in my paper recorded several cases of my 
own, together with a number collected from surgical literature. 
At that time I also made quite a search in museums for speci- 
mens of this fracture, and was surprised to find how many 
there were, though nearly all of them had no clinical histories 
attached to them. They were specimens of the fracture, 
united with deformity, which had been found in dissecting- 
rooms (Fig. 27). The illustrations now shown you give an 
idea of the characteristic appearance of some of these speci- 




Fig. 34. 

Dissected specimen in cabinet of New York hospital showing deformity in 
radius after fracture with forward displacement. 

mens (Fig. 34). E. W. Smith, in his book on " Fractures and 
Dislocations," published about fifty years ago, calls attention 
to this injury and gives an illustration of a plaster cast made 
from such a case. 

On account of Smith having called attention to the fracture, 
it is sometimes denominated " Smith's fracture of the radius." 
The usual fracture with backward displacement of the lower 
fragment was especially studied many years ago by Colles, 
and is often to this day called "Colles's fracture." The injury 
which you see in this boy is accordingly sometimes called a re- 
versed Colles's fracture. It is interesting to remember that 
the authors whose names have been attached to these injuries 
were both Irish surgeons living in Dublin. 



146 THE MODERN" TREATMENT OF FRACTURES. 

There ought to be very little difficulty, I think, in recog- 
nizing the injury under consideration if the surgeon only re- 
members that it is a fracture of possible occurrence. The 
great frequency of the fracture with backward displacement 
of the lower fragment gives rise to careless diagnosis when 
injuries of the radius near the wrist-joint occur. The de- 
formity is cpiite different, and careful inspection ought to 
make the nature of the accident apparent (Fig. 25). The 




Fig. 35. 

Skiagraph showing bend at lower end of radius due to unreduced fracture 
with forward displacement. The prominence of the head of the ulna 
at the back of the wrist is well shown. 

ordinary fracture of the radial base occurs from blow- in 
which the force of the blow is received on the palm of the 
hand. It is probably that the opposite displacement is due 
to the application of force upon the back of the hand tend- 
ing to strongly flex the wrist. One of the cases of the injury 
which I have seen occurred in a man who fell while playing 
football with his hand and wrist doubled under him in a 



RADIAL FRACTURE DISPLACED FORWARDS. 147 

position of flexion. In the other cases it was not perfectly 
clear in what manner the force had been applied. 

The late Mr. Callender of London reported a case some 
years ago in which fracture took place from galvanic stimula- 
tion of the muscles. In this instance the bone was apparently 
broken by forced flexion, clue to the violent contraction of the 
flexor muscles when the patient took hold of the handles of 
the galvanic machine and received the shock. 

Some experimental observations which I have made in the 
anatomical laboratory and a study of the reported cases lead 
me to believe that the fracture is caused in three ways. Some- 
times the lower end of the bone is torn oft' by a strain exerted 
through the posterior ligaments during extreme flexion, when 
the force is applied to the back of the hand. In other cases 
there may be a crushing of the anterior part of the base of 
the radius between the wrist-bones and the shaft, so that the 
lower fragment is forced forward; or the shaft of the bone and 
the base may be driven into each other by the force of the in- 
jury, causing a sort of mutual impaction. In a third series of 
cases the bony tissue of the radial base may give away at its 
weakest point by decomposition of the forces to which the bone 
is subjected. 

The symptoms of the lesion will depend somewhat upon the 
line of fracture, which may be oblique or transverse. There 
may be a great deal of anterior displacement, as in the woman 
whose plaster cast is shown you, with very little displacement 
to the radial side; or there may be, as in the present case, a 
great deal of displacement to the radial side, due to crushing 
of the tissue of the base of the radius, with very little anterior 
displacement. When the lateral displacement is great, the 
head of the ulna becomes markedly prominent at the ulnar 
border of the wrist; whereas if the displacement of the lower 
fragment forward is great, the head of the ulna makes a 
marked projection on the dorsum of the wrist. 

The appearance of the back and front of the wrist is very 



148 THE MODERN TREATMENT OF FRACTURES. 

different from that which occurs in the ordinary fracture in 
this region, as will be seen by comparing the casts which I 
show yon: one is a case of an ordinary or classic fracture of 
the lower end of the radius, the other is the cast of the woman 
whom I presented at this clinic a couple of years ago. The 
same thing is evident if you look at this boy's wrist with care, 
though it is not marked as in the cast of the woman's hand, 
because, as I have said, the forward displacement is not so 
great. 

Here is an illustration of an experimental fracture in the 
cadaver which I made for the class here some years ago and 



Diagram of Deformity in Fracture wifh Forward Displacement 



Diagram of Deformity in Fracture with Backward Displacement 
Fig. 36. 

used for illustrating the deformity in the classic fracture with 
backward displacement. You will see in the fracture with the 
carpal fragment thrust forward an elevation running across 
the back of the forearm obliquely upward from the ulnar to 
the radial side. This elevation is more marked at the ulnar 
side of the arm, and is due to the lower end or head of the 
ulna, which is left behind, as it were, when the lower frag- 
ment of the radius with the hand attached to it is carried 
forward by the injury. This eminence on the back is quite 
different from the elevation on the radial side of the dorsum 
found in fracture of the lower end of the radius with back- 
ward displacement. In that lesion the elevation is greater 
on the radial half of the forearm, and you can feel with your 



RADIAL FRACTURE DISPLACED FORWARDS. 149 

finger placed upon the back of the shaft of the radius the ele- 
vation corresponding to the dorsal surface of the lower frag- 
ment ; and the ulna has nothing to do with the prominence on 
the back of the forearm. 

In the fracture under consideration, the posterior surface of 
the forearm and wrist shows three planes, as it were, — the 
plane of the back of the forearm, followed by a second plane 
descending downward towards the back of the hand; and then 
the plane of the back of the hand, which is at a lower level 
than that of the forearm, but more or less parallel to it. This 
causes a sort of furrow below the dorsal elevation; but the 
dorsal elevation is not raised above the general level of the 
back of the forearm. It is caused by the lower fragment 
being thrust forward and leaving an abrupt termination to the 
plane of the back of the forearm. Pressure will make the 
hollow more evident, and show that the base of the radius is 
farther front than normal. In the classic fracture, however, 
the plane of the back of the forearm is altered by a mound 
or hump near the wrist-joint, and from the top of this eleva- 
tion there descends a plane corresponding with the back of the 
hand. The rude diagram which I make on the blackboard 
shows you the difference between the two injuries (Fig. 36). 

On the palmar surface of this boy's wrist you see a promi- 
nence which is quite different from that produced by the 
lower end of the upper fragment in the classic fracture. 
The former is nearer the wrist than the latter, and has its edge 
directed upward instead of downward towards the hand, as 
in the case when the prominence is due to the lower end of 
the upper fragment as it is in the usual fractiu-e. In this boy 
the position of the lower fragment is, as I have previously 
told you, well shown when the boy contracts the flexor 
muscles in bending his fingers, because the muscular bellies 
are then drawn upward and the tendons made more tense 
over the fragment. 

The normal curve of the anterior surface of the radius at 



150 



THE MODERN TREATMENT OF FRACTURES. 



its lower end disappears when the fragment attached to the 
carpus is thrown forward. There may, however, be made 
by this displacement a more marked cavity than usual in the 
normal bone, but it is farther away from the hand. The 
change in the length of the radius due to the shortening of 
the bone, caused by the impaction or crushing of the spongy 
tissue of the base or the displacement, makes the styloid proc- 
ess of the radius to be nearer the elbow than normal. This, 
of course, occurs also in fractures of the lower end of the 




Fig. 37. 

Outlines of both hands and wrists, showing on the left the elevation of the 
radial styloid and increased width of the wrist due to fracture. Taken 
with the palm laid on the paper and outlines traced with a pencil. 

radius with backward displacement. JSTormally, as you 
know, the styloid process of the radius is farther from the 
elbow than that of the ulna. You will notice in this boy's 
hand that there is an elevation — that is, a displacement to- 
ward the elbow — of the ulnar styloid of about three-eighths of 
an inch. You can estimate this quite well by placing both 
hands of the patient upon a. piece of paper laid upon the 
table, with the palmar surface next the paper (Fig. 37). 
If you make an outline of the hand and wrist with a pen- 



RADIAL FRACTURE DISPLACED FORWARDS. 151 

cil and then drop a perpendicular line from the styloid 
processes by means of a rule laid against them, you can mark 
their position on the rude outline which you have drawn. I 
show you this in the diagrams on this paper. An increase in 
abduction is also permitted after fractures of the radial base, 
due to the change in the plane of the articular surface caused 
by the displacement. This occurs in fractures with forward 
displacement as well as in those with backward displacement. 

The differential diagnosis between fractures of this sort 
and dislocation of the wrist is to be made by a study of the 
deformity and the manner in which dislocations are reducible 
with a distinct snap. This fracture, as well as the one with 
displacement backward, looks somewhat like a dislocation, 
and requires considerable force to push the fragments into 
proper position. There is, however, a grating sound when the 
lower fragment is forced into place different from the snap 
elicited when the dislocation is reduced. 

The preternatural mobility and crepitus which are found 
in most fractures may be absent in this injury, because the 
fragments are impacted. When the fragments have been 
put in proper position by the application of considerable force 
they usually remain in place, because the broad surfaces of 
contact prevent recurrence of the deformity. This is due 
to the fact that the fracture takes place through the broad- 
.ened portion of the bone which constitutes the base. 

The treatment of a recent fracture of this sort is immediate 
and complete reduction of the fragments so as to restore the 
normal outline of the bone. To do this the surgeon should 
grasp the metacarpus of the patient with one hand and the 
lower part of the forearm with the other hand, and make 
strong pressure with his thumb on the carpal fragment so as 
to force it into proper position in relation to the shaft. It 
is well to have the patient's hand with the palm upward, so 
that the surgeon's thumb can be readily placed upon the 
lower fragment just above the ball of the patient's thumb. 



152 



THE MODERN TREATMENT OE FBACTTJBES. 



Traction and counter-traction with sudden extension of 
the hand backward at the wrist with pressure on the lower 
fragment will usually reduce the fracture. A light splint of 
wood an inch wide and six inches long applied along the back 




Outline of normal baud and 
on paper. 



Fig. 38. 
rrist in full abduction. Taken with palm 



of the wrist so as to prevent motion at the wrist-joint makes a 
very satisfactory retentive dressing. If the surgeon prefer 
he may apply a molded metal splint, or a splint made of plas- 
ter of Paris, to the palmar aspect of the forearm and hand. 
This splint must, of course, correspond with the normal curva- 
ture of the lower portion of the radius on its palmar surface. 
If there is not much tendency to displacement and the pa- 
tient can be relied upon to put no strain upon the hand and 
wrist, a rigid splint may be dispensed with, and the motions 
of the joint be restricted by a simple wristlet or band of ad- 
hesive plaster applied around the wrist-joint, in the manner 
which I have so often shown you in the treatment of the 
ordinary fracture of the lower end of the radius. 

In the present case no treatment is indicated, for the boy 
has perfect motion and is not particularly annoyed by the 
deformity due to non-reduction of the fracture at the time of 
the accident. Osteotomv could be done, but the result would 



RADIAL FRACTURE DISPLACED FORWARDS. 



153 



probably give Mm no better use of the hand; and the slight 
improvement in position would scarcely be valuable enough 
to justify the operation. The slight pain he feels when he 
uses the hand in heavy work is probably due to the disad- 




Outline of injured hand and wrist in full abduction. Taken with palm on 
paper. The great increase in abduction due to change in lower end 
of radius is evident when this diagram is compared with its com- 
panion. 



vantageous manner in which the muscles act on account of the 
abnormality in the shape of the bone. 



XIX. 

THE TREATMENT OF FRACTURES OF THE LOWER 
PART OF THE TIBIA AND FIBULA.* 

Withes the last few days there have been admitted to the 
hospital a considerable number of fractures of the lower 
extremity, and it will be interesting, perhaps, to show you 
some of them, as they illustrate several classes of fractures 
in this region. The cases presented are good illustrations of 
the forms of fracture of one or other bone of the leg. In two 
of them the lower portion of the fibula is broken with no 
injury to the tibia. One is an open or compound fracture of 
both bones due to the passage of a heavy cart across the front 
of the leg. The others are closed or so-called simple fractures 
in the ankle region, interesting because there is a marked 
tendency to displacement. The fifth patient is a woman 
whom you saw a few days ago operated upon because of the 
great displacement of the fragments due to contraction of the 
muscles of the calf. In her case the fracture involved the 
lower end of the fibula and the outer portion of the lower 
end of the tibia without involving the internal malleolus. 

These eases are brought before you to illustrate the vari- 
ous methods which are adopted to treat, successfully these 
common injuries. The fibular fractures unaccompanied by 
fractures of the tibia require very little special treatment, since 
the tendency to deformity is not great. I generally keep 
them in an ordinary fracture box or tied up in a pillow with- 
out a fracture box for two or three days and then apply an 
ambulant splint of plaster of Paris and discharge the patient 
on crutches. They are permitted to dispense with the 
* From the "International Clinics," 1897. 

154 



FRACTURES OF TIBIA AND FIBULA. 155 

crutches and walk on the splint with the support of a cane 
in a very few days. One of these cases, you see, has the 
ambulant splint already applied, and is now a dispensary pa- 
tient. In applying the ambulant splint of plaster of Paris 
it is important to make it strong enough to bear the weight 
of the patient in walking. Hence you must have the upper 
part of the splint applied to the head of the tibia and the 
condyles of the femur in such a way that the patient's weight 
comes upon the plaster of Paris at its upper portion and is 
supported by the stiff splint which extends below the sole of 
the foot. In this manner the foot and leg hang as it were in- 
side the splint, which acts a good deal as does an artificial leg 
within which the stump is placed. In order to prevent the 
weight coming upon the fragments when the patient walks, 
an ambulant splint should be applied with a considerable 
amount of cotton put under the sole of the foot. This 
makes the splint a little longer than the patient's limb and 
allows the injured bones to be saved from contact with the 
sole of the splint during walking. 

Fractures of both tibia and fibula near the ankle are fre- 
quent and often serious injuries. Both bones may be broken 
without any complication or there may be a good deal of 
comminution, with fracture of one or both malleoli. The 
lower end of the tibia is seldom broken without the fibula 
being similarly injured, though the fracture of the smaller 
bone will probably be at a higher level. The woman before 
you had such a fracture, due to a fall which probably caused 
great eversion of the foot. The fibula was broken an inch 
or so above the malleolus, and the outer portion of the tibia 
split off by a line of fracture running from the interior of the 
ankle-joint upward and outward and obliquely backward. 
There was no fracture of the malleolus. The obliquity of 
the line of fracture and the impact of the blow which caused 
the injur}' drove the foot outward, causing great eversion and 
nearly thrust the tibial malleolus through the skin on the 



156 THE MODERN TREATMENT OF FRACTURES. 

inner side of the ankle. \Ve have attempted to keep the 
fragments in place by putting the limb in a fracture-box and 
trying proper padding. It is impossible, however, to reduce 
the fracture, because of tbe obliquity of the fracture permit- 
ting tbe calf-muscles to cause overriding and backward dis- 
placement, as "well as lateral deformity. Tbe deformity can 
be best corrected, in my opinion, by subcutaneous section of 
the tendo Achillis, as in the ease operated upon a few days 
ago. This will relieve the muscular tension that displaces 
the lower fragment. Tbe woman some time ago received a 
similar fracture of the other leg, and I show you how greatly 
it is now deformed because the fragments were never 
properly reduced. You see how markedly the heel projects 
backward, and how the internal malleolus projects at the in- 
ner side of the leg because of tbe manner in which the foot 
was allowed to remain in the abnormal position caused by 
the fracture. This deformity makes her lame. It is curious 
that the woman should now have received a similar fracture 
of the other leg. I shall, therefore, have the tendon cut by 
the resident surgeon; and, now that he has done it, you see 
how easy it is to put the foot in the proper position and re- 
duce the deformity at the seat of fracture. 

The other woman had this operation done upon her a few 
days ago, and has, as you see, a perfectly symmetrical pair of 
feet and ankles. 

The tenotomy wound is closed with a little gauze held in 
place by collodion, and a plaster of Paris dressing is now ap- 
plied from the toes to a short distance above the knee. Tbis 
puts the parts at rest, and there is no tendency for displace- 
ment to occur. The tendo Achillis will soon unite and her 
muscular power will be as great as ever. This method of 
treating this fracture is a very valuable one, which is often 
forgotten or overlooked. Its value I have frequently prove! 
to my own satisfaction. 

It is interesting that two patients with a similar injury 






FRACTURES OF TIBIA AND FIBULA. 157 

should be admitted within a few days of each other, and it 
is especially interesting that the patient just operated upon 
should show the result of a similar lesion of the other leg im- 
properly treated. 

This man has a fracture of both tibia and fibula, a short 
distance above the ankle, in which there is a great tendency 
for the lower fragment to project forward. He was treated 
for a few days in a fracture box which was suspended from a 
gallows erected over the bed. The fracture box is a conven- 
ient method of dressing fractures of the tibia and fibula, since 
the degree of pressure and the position of the padding can 
be changed in accordance with the tendency to displacement 
and the amount of swelling. It is always better to suspend 
a fracture box, because then the patient can move about in 
bed without displacing the fracture. The height at which 
the box is suspended is easily altered by having a slide of some 
sort upon the suspending rope. It often rests the patient 
very much to have the fracture box lowered or raised, since 
this enables him to bend his knee at a different angle, and 
therefore gives relief from the cramped position necessitated 
if the fracture box is lying upon the bed. You have seen in 
the wards how easy it is for a patient, with a fractured leg 
thus suspended in a fracture box, to move his hips about from 
one portion of the bed to the other, and with what ease the 
nurses can use the bedpan or change the sheets. After this 
fracture was treated by a fracture box for a few days the 
regular plaster of Paris splint was applied and cut down the 
front as soon as it was hardened. "We accomplish this by 
laying a long strip or tape of lead upon the front of the leg 
before the plaster of Paris bandage is applied. As soon as 
the plaster is hard a sharp knife is used to divide the plaster 
over the lead strip, which prevents the point of the knife cut- 
ting the patient. The lead is so soft that the point of the 
knife is not damaged. The splint was opened, as stated, and 
has been repeatedly removed and reapplied so that the pro- 



158 THE MODERN TREATMENT OF FRACTURES. 

jection forward of the lower fragment could be watched and 
corrected. 

By elevating the heel, by putting cotton .into the splint at 
the place where the heel is to rest, the resident surgeon has 
been able to overcome the tendency to displacement. A per- 
manent plaster of Paris splint will now be applied and will not 
be cut, since the bones have shown a tendency to remain in 
proper position. Before applying a plaster of Paris bandage 
it is well to cover the limb with a bandage of flannel or lint, 
which prevents the skin being made uncomfortable by the 
plaster of Paris becoming entangled in the hairs or from un- 
due pressure. A very nice method of accomplishing this is to 
use a long stocking, such as is worn by women, which can be 
drawn over the leg, and fits more neatly and smoothly than 
any other bandage. A plaster of Paris splint is then made- of 
the stocking. 

I seldom use fracture boxes for more than a few days, since 
the plaster of Paris splints, or, indeed, any plastic splints, are 
much lighter, and are more convenient when the swelling has 
diminished and the tendency to displacement has been re- 
lieved. 

An ambulant splint is hardly proper for this patient, be- 
cause there has been such a marked tendency to overriding. 
In a few days, however, he can get out of bed and go on 
crutches, if he is careful not to put the foot to the ground. 
In other words, he can be allowed to walk about with crutches, 
but not with a cane. I fear that the ambulant splint would be 
likely to promote displacement. The advantages of having 
patients with fracture of the leg out of bed early are the 
improved circulation of the parts, which is gained by a nor- 
mal position of the limb, and the shortening of the period of 
confinement to the bed, which interferes with the occupation 
of the patient and his comfort. 

The last case is one of open fracture of the tibia and fibula, 
due to the passage of a wagon-wheel over the limb. Such 



FRACTURES OF TIBIA AND FIBULA. 159 

fractures are infected, and are much more serious than closed 
fractures. The word " compound," which is applied to open 
fractures, is an unsatisfactory term, since it does not explain 
its own meaning. The term " simple," applied to fractures 
not exposed to the air by a wound, is equally unscientific and 
objectionable. To call one an " open " and the other a 
" closed " fracture at once signifies the condition present. It 
is difficult to get rid of the terms " simple " and " compound," 
however, which have been so long used by English-speaking 
surgeons. Surgeons of other nations do not use these terms. 
In order to make this open fracture aseptic I shall etherize 
the patient, lay open the wound freely, turn out the clots, 
sterilize the parts with corrosive sublimate solution, wire the 
fragments together after having drilled a hole through the 
upper and lower piece of bone. A couple of drainage tubes 
will be inserted and the wound dressed with sterilized gauze. 
Over the whole is applied a plaster of Paris splint. This will 
not be removed unless pain or rise of temperature indicates 
that the wound at the seat of fracture is not running an asep- 
tic course. In many fractures treated in this way the plaster 
of Paris splint need not be removed for several weeks. Where 
there is a great deal of comminution as well as an opening 
leading to the fracture, as in this case, it is not unlikely that 
the attempt at sterilization will fail, and that it may be neces- 
sary to open the splint, to give exit to pus and to allow thor- 
ough and frequent irrigation of the wound. The patient was 
told before etherization that it was quite possible that the 
leg would have to be amputated because of the severe crush- 
ing injury. It seems, however, that it may be saved, since 
both the anterior and posterior tibial arteries can be felt beat- 
ing at tbe ankle. 



INDEX. 



Advances, recent, 31 

Advantages of exploratory incision, 4 

refracture, 63 
Ambulant Splints, 31, 155 
Anaesthesia, 14 
Anchylosis, 5, 24 
Anchylosis of elbow, 78 
Angle of humerus and ulna, 79, 97 
Arthrotomy in dislocations, 7 



B 



Bandage, primary, 3! 



Cranium, fractures of, 65 

syllabus of treatment, 76 



D 



Deformity, in fractures of radius, 
148, 150 

prevention of, 13 
relief of, 44 
Diagnosis, mistaken, 13 
Dislocations, exploratory incision 

in, 2 
Doctrine, false, in treatment, 23 



Elbow, extended, in fractures of 

humerus, 78, 90, 101 
Exploratory incision, in closed frac- 
tures, 2, 78, 88 

advantages of, 4 
in dislocations, 6 

advantages of, 7 
Extremities, fractures of, 13, 31, 45 



False doctrine in treatment, 23 
Fat embolism, 5 
Fibula, fractures of, 154 
Fixation by nailing, 82 
Flexion, acute, in condyloid frac- 
tures of humerus, 91 
Force in treatment of fractures of 

radius, 130 
Fracture box, 157 
Fracture nails, 11, 87 
Fractures, closed, exploratory in- 
cision in, 2 

condyloid, of humerus, 78 
greenstick, 15 
impacted, 16 
of clavicle, 27 
cranium, 65 
extremities, prevention of 

deformity in, 13 
humerus, 78, 92, 96 
nose, 26 

radius, 92, 96, 105, 118 
forty-three cases, 121 
ignorance regarding, 

118 
necessity of force, 130 
needlessness of 

splints, 124 
osteotomy in, 116 
refracture in, 128 
with forward dis- 
placement, 133,140, 
142 
tibia and fibula, 154 
recent advances in treatment 

ment of, 31 
simplicity in treatment, 34 
subcutaneous nailing in, 10, 

78 
with displacement, 10 



Greenstick fractures, 15 



162 



Hammer forceps, 87 
Humerus, condyloid fractures of, 
78, 92, 96 



Ignorance regarding fracture of 

radius, 118 
Incision, exploratory, 2, 78, 88 
Impacted fractures, 16 



Lead water and laudanum, harmful 

effect of, 93 
Levis's extension plate, 53 

M 

Motion, passive, 24, 112 

N 

Nailing, subcutaneous, in fractures, 

10, 78, 82 
Nails, fracture, 87 
Necessity of force in fractures of 

radius, 130 
Needlessness of splints in fractures 

of radius, 124 



R 

Radius, fractures of, 92, 96, 105, 
118, 133, 140, 
142 
forty-three cases, 

121 
ignorance re- 
garding, 118 
necessity of force 

130 
needlessness o f 

splints, 124 
osteotomy in, 116 
refracturein, 128 
with forward dis- 
placement, 133, 
140, 142 
Recent advances, 31 
Reduction of fractures, tenotomy in, 

20 
Refracture, 33, 44, 63, 128 
results of, 62 



S 



Simplicity in treatment, 34 
Skiagraphs, 88 
Skiagraphy in dislocations, 8 
Splints, molded, 17, 39 

needlessness of, 124 
Subcutaneous nailing, 10, 78, 82 

tenotomy, 20, 32 
Syllabus of treatment of fractures 
of cranium, 76 



Osteotomy, 128 



Passive motion, 24, 112 
Prevention of deformity in fractures, 
13 



Tenotomy, subcutaneous, 20 
Tibia, fractures of, 154 
Treatment, simplicity in, 34 
Trephining, 66, 76 
mortality of, 66 



Vicious union, 6 



OCT 28 1899 



